Ministry of Health,
Government of Southern Sudan
Basic Package of Health and Nutrition
Services
For Southern Sudan
Final Draft – January 2009
ACKNOWLEDGMENT
The review of Basic Package of Health Services (BPHS) for Southern Sudan has been made
possible through the combined efforts of many organizations and individuals. First and foremost,
financial and technical assistance provided by International Bank for Reconstruction and
Development – the World Bank (WB).
Let me take this early opportunity to express profound gratitude to the Dr. Nathan Atem, the
Director General Primary Health Care and his entire team for leading the review process that
reqired much patience and concentration. Special thanks go Dr. Makur Kariom, the director
Reproductive Health (RH-PHC), Dr. Antony Lako, the Director Community Base Health Care
(CBHC-PHC), Dr. Lueth Garang, the Director Health Education and Promotion (HEP-PHC) for
devoting time to make technical input in the document. I wish to specially mention Ms. Janet
Michael, the Director General Nursing Services for her committed advocacy for maternal
services within the BPHS, given the challenge of maternal mortality in Southern Sudan. Let me
also take the opportunity to specially thank Dr. John Rumunu, the Director General, Preventive
Health and his entire team in setting the pace in linking the BPHS to the strategies for the
common endemic infection programs and with him, Dr Thabo Othwonh, the Manager Malaria
Program, Dr. Rober Azairwe, the Team Leader MSH and advisor Malaria Program, to the
different directorates entire Southern Sudan Health fraternity for the Nutrition and the
Reproductive Health Technical Working Groups their tireless efforts in reviewing and making
most valuable technical contributions to the editing of this document. The ministry also
recognizes contributions from Dr. Olivia Lomoro, the DG Health Research, Policy, Planning and
systems development, Dr. Richard Lagu, Dr. George Rae and the entire staff of the directorate. Other
significant contributions came from Ms. Victoria Jaba Eluzai, Dr. Ayat Jervas, Mr, Samwel Makoy, Mr.
Ali Ngor, Dr. Yatta Lugor and Dr. Stanley Ambajoro, MS. Bibian Alex Lotio, Catherine Jurua Otto and
Rebbecca Alum William
Special thanks go to Dr. John Alwar for ensuring comprehensiveness and sound technical edit of the final
version of this the document and to Dr. Chris Lewis, Tearfund, Ms. Marcie Cook, PSI and Dr. Tessa
Matholie, Malaria Consortium who assisted with editing the second draft of the document. The Staff of
Southern Sudan Offices of United Nations Fund for Population Activities (UNFPA), World Health
Organization (WHO), and the International Committee of the Red Cross (ICRC), Sudan Health
Transformation (SHTP), Management Sciences for Health (MSH) and Help Age International, made
specific inputs to ensure the document is in line with the Interim Health Policy of Sothern Sudan and
international state of the art practices in Primary Health Care.
Thank you all.
Dr. Majok Yak Majok
The Under Secretary,
Ministry of Health, Government of Southern Sudan
2
Foreword
Following the signing of the Comprehensive Peace Agreement (CPA) on January 9 th, 2005, the
SPLA/SPLM committed itself to establishing a right based approach to development facilitation. The
interim Constitution Guarantees every Southern Sudanese the right optimal health. The Government of
South Sudan (GoSS) has therefore developed a health policy founded on the Primary Health Care (PHC)
as the strategy to make quality health care universally accessible. This policy will form an integral part of
the country's development program to ensure rapid improvement of health of the Southern Sudanese. The
PHC approach considers full community involvement in decision making as the key to successful
provision of health services. This in turn requires a gender balanced representation in the structure for
health services governance from the grass root to the GoSS levels.
Ongoing health sector reforms is adapting of priority actions and interventions which will most efficiently
and effectively reduce mortality, disability and morbidity. The interventions will be made equitably
available and accessible at costs that are affordable to the government and the communities and families.
Whereas low cost health interventions that can be delivered with very humble technology have been
developed, they require efficient managerial systems for their impact to be realized. The current
development of the health system takes a two tier approach. The first is the development of sound
systems for planning, management, monitoring and evaluation. The second is the concurrent delivery of
priority services that address the priority health problems.
This document provides guidelines, which will help health service managers, and providers at different
levels, the village, the primary health care units (PHCU), the primary health care centers (PHCCs), the
county health department (CHD) and the state Ministries of Health (SMoH) in implementing various
components of the Basic Package of Health Services (BPHS). The SMoHs and CHDs have the
responsibility of ensuring the implementers of health programs are trained in and use this package in
evidence based planning and realistic budgeting for effective health service delivery.
The objective of having a package is to offer services, which maximize value for money by achieving
greater health improvements. It is my hope and conviction that the implementation of BPHS will increase
access to quality essential health services and expedite progress towards the attainment of the MDGs in
Southern Sudan. To ensure equity of quality care the establishment of levels of services, with their
packages especially in Maternal and child health have taken into consideration the unique geographical,
climatic and spatial population distribution features of Southern Sudan.
H.E. Dr. Joseph Manytuil Wejang
Minister of Health – Government of Southern Sudan
3
TABLE OF CONTENTS
ACKNOWLEDGMENT.........................................................................................................2
Foreword..................................................................................................................................3
TABLE OF CONTENTS........................................................................................................4
ABREVIATIONS AND ACRONYMS..................................................................................8
1.INTRODUCTION................................................................................................................9
2. COUNTRY BACKGROUND...........................................................................................10
2.1. Land and People..................................................................................................................10
2.2. State of Health and Health Services in Southern Sudanese................................................10
3. BASIC PACKAGE OF HEALTH SERVICES (BPHS)................................................12
3.1. Overview.............................................................................................................................12
3.2. The Purpose of BPHS.........................................................................................................12
3.2.3. The Values and Principles......................................................................13
4. COMPONENTS OF THE BASIC PACKAGE OF HEALTH SERVICE...................14
4.1. Overview.............................................................................................................................14
4.2. Integrated Reproductive Health Services (IRHS)...............................................................14
4.2.1. Essential Obstetric Care (EOC) .............................................................14
4.2.2. Family Planning and Women’s Health (FP/WH)...................................15
4.2.3. Adolescent Sexual Reproductive Health Services (ASRHS) ................15
4.2.4. Men’s Reproductive Health Services (MRHS)......................................16
4.3. Integrated Essential Child Health Care (IECHC) ..............................................................16
4.3.1. Community Based Child Survival Program (CBCSP)...........................16
4.3.2. Expanded Program on Immunization (EPI)...........................................16
4.3.3. Essential Nutrition Action (ENA)..........................................................17
4.3.4. Home treatment of Malaria, Diarrhoea and Pneumonia.........................17
4.4. Management of endemic Common Endemic Diseases (MCED).......................................17
4.4.1. Malaria....................................................................................................18
4.4.2. Diarrhea, enteric infections and infestations..........................................19
4.4.3. Acute Respiratory Infection (ARI).........................................................20
4.4.7. Neglected Tropical Diseases (NTD).......................................................22
4.4.8. Primary Eye Care and Visual Health......................................................23
4.4.9. Oral Health.............................................................................................23
4.4.10. Mental health
.........................................................................24
4
4.4.11. Community based prevention and care for common injuries and
rehabilitation ....................................................................................................24
4.5. Integrated Disease Surveillance and Response (IDSR) .....................................................25
4.6. Health Education and Promotion .......................................................................................25
4.6.1. The Promotion of health seeking behavior - targeting epidemiological
priorities............................................................................................................26
4.6.2. Basic package of health and nutrition for Schools.................................26
4.6.3. Community based nutrition and food security program (CBNFSP)......27
4.6.4. Community management of environmental health and hygiene (CMEH)
..........................................................................................................................27
At work place, CMEH will develop Healthy Workplaces activities to promote
and protect the health and safety of people at work by preventing workplacerelated fatalities, illnesses, injuries, and personal health risks. These will
include gender relationships and perspectives at work place using STI and
HIV/AIDS as entry points. Training in prevention and first aid for physical
injuries and snake-bite are highly relevant to the situation in Southern Sudan.
Other work place interventions will target lifestyle related diseases including
obesity, high blood pressure and diabetes. Healthy healthcare settings are
absolutely essential to successful health promotion programs. Again,
HIV/AIDS as one of the health workplace programs will be useful entry
points................................................................................................................27
4.7. Monitoring and evaluation .................................................................................................28
4.7.1. Health Management Information System (HMIS) ................................28
4.7.2. Periodic M/E ..........................................................................................28
4.7.3. Operational research ..............................................................................29
The bulk of health problems and health systems challenges in developing countries lie
at the primary level. A significant number of these require operational research to
establish causalities and consequences. Much operational research currently takes place
in Southern Sudan, both initiated from within the country and from outside. However,
there is no existing mechanism for “quality control” to ensure reliable evidence and no
existing forum for disseminating findings and for ensuring that findings filter through
into improved policy and practice. The GoSS-MoH has established a Directorate of
Research, Planning and Health System Development (DRPHSD) which is responsible
for operations research. This should inform planning to ensure cost-effectiveness and
attainment of objectives. The BPHS lead agents, together with the research unit within
the DRPHSD, will work together to coordinate and housing proposals and study
reports, with an improved database of research-related activities relevant to each state
whether the proposals originate from within or outside Southern Sudan.......................29
Table1. BPHS at a Glance.....................................................................................................30
5
Table2. Summary of Integrated Reproductive Health Care (IRHC) 1............................32
Emergency Obstetric and Neonatal Care (EmOMNC).....................................................32
5. SERVICE NORMS AND STANDARDS BY LEVELS OF CARE..............................35
5.1. Overview.............................................................................................................................35
5.2. Village Level. ....................................................................................................................35
5.3. Primary Health Care Units (PHCUs). ................................................................................36
5.4. The Basic Emergency Obstetric and Neonatal Care Primary Health Care Centre
(BEmONCPHCC)......................................................................................................................37
5.5. Comprehensive EmONC Primary Health Care Centre (CEPHCC). .................................38
5.6. Boma Health Committees (BHCs)......................................................................................39
5.7. The County Health Department..........................................................................................39
6. MANAGEMENT AND ADMINISTRATIVE ARRANGEMENTS.............................44
6.1. Management........................................................................................................................44
6.2. Logistics Establish functioning logistics system for efficient delivery of BPHS. .............45
6.3. Extending the national health management information system (HMIS) .........................45
BIBLIOGRAPHY..................................................................................................................49
6
LIST OF TABLES
Table1. BPHS at a Glance.....................................................................................................28
Table2. Summary of Integrated Reproductive Health Care (IRHC) Emergency
Obstetric and Neonatal Care (EmOMNC)..........................................................................29
Table3. Summary of Integrated Reproductive Health Care (CERH2) – Preventive
Reproductive Health Services (PRHS) ……………………………30
Table4. Summary of CBHC1 - Integrated Essential Child Health Care ………..31
7
ABREVIATIONS AND ACRONYMS
ACT
ASRH
ARI
BCC
BEMoNC
CBHC
CEMoNC
CHD
CHW
CMOH
CPR
EmONC
EWARN
GAM
GAVI
GFATM
GOSS
HAT
HHP
HMIS
HNCG
IMCI
ITN
IEC
IECHC
IPT
JAM
LF
LLINs
MCH
MDG
MDTF
MRHS
MICS
MISP
MoH
MUAC
MVA
NGO
NID
NTDs
OF
ORS
PICT
PMTCT
SBA
SSRRC
STI
Artemisinin-based Combination Treatment
Adolescent Sexual and Reproductive Health
Acute Respiratory Infection
Behavioral Change and Communication
Basic Emergency Obstetrics and Neonatal Care
Community Based Health Care
Comprehensive Emergency Obstetrics and Neonatal Care
County Health Department
Community Health Worker
County Medical Officer of Health
Contraceptive Prevalence Rate
Emergency Obstetric and Neonatal Care
Early Warning Alert and Response Network
Global Acute Malnutrition
Global Alliance for Vaccines and Immunization
Global Fund for AIDS, Tuberculosis and Malaria
Government of Southern Sudan
Human African Trypanosomiasis
Home Health Promoter
Health Management and Information System
Health and Nutrition Consultative Group
Integrated Management of Childhood Illnesses
Insecticide Treated Net
Information, Education and Communication
Integrated Essential Child Health Care
Intermittent Preventive Treatment (of malaria)
Joint Assessment Mission
Lymphatic Filariasis
Long-Lasting Insecticide-Treated Nets
Maternal and Child Health
Millennium Development Goal
Multi-Donor Trust Fund
Men’s Reproductive Health Services (MRHS)
Multiple Indicator Cluster Survey
Minimum Initial Service Package
Ministry of Health
Mid Upper Arm Circumference
Manual Vacuum Aspiration
Non-Governmental Organization
National Immunization Day
Neglected Tropical Diseases
Obstetric Fistula
Oral Rehydration Solution
Provide initiated Counseling and testing
Prevention of Mother to Child Transmission (of HIV)
Skilled Birth Attendant
Southern Sudan Relief and Rehabilitation Commission
Sexually Transmitted Infection
8
WRHS
Women’s Reproductive Health Services (WRHS)
1. INTRODUCTION
Healthcare is essential for the improvement of the standard of living in any nation and primary healthcare
is the focus for action since it can be made universally accessible through a community based approach to
health service delivery. The major gaps in health care currently are the availability, accessibility and
efficient management of service provision. In the urban fringe and the rural areas this translates to time,
cost, comfort, convenience and safety, all of which may affect care seeking practices and the demand for
modern health care. A health system in which the lower facilities that can offer low cost effective services
function poorly results in the overload of higher hierarchy of health facilities where service provision is
more expensive thereby overburdening the national health budget. It also decreases the efficiency and
effectiveness of health services and health programs because delays in simple health interventions result
in life threatening complications leading to high fatality rates of severe disabilities. Currently the
development of health facilities network in Southern Sudan takes and ad-hoc growth pattern and does not
consider the geographical terrain or population factors. In addition health inequalities are perpetuated by
difference in economic standards of the people.
The Basic Package of Health Services (BPHS) in Southern Sudan is developed as the medium term
strategy to promulgate the long term Health Policy (HP) of the Ministry of Health (MoH) Government of
south Sudan (GoSS) that is founded on Primary Health Care (PHC). It comprises a selection of the most
cost-effective elements of PHC to be delivered in an integrated way to enhance progress towards the
Millennium Development Goals (MDG). BPHS sets health service delivery norms and standards to guide
planning, implementation, monitoring and evaluation at the community, Primary Health Care Unit
(PHCU), Primary Health Care Center (PHCC), and by the County Health Department. The document
contextualizes BPHS to Southern Sudan, positions health service provision within the overall economic
and social development framework, and relates it to similar programs in other countries to enable
international comparison.
This introduction section guides the reader through the rest of the document, outlining the contents of
each section to enable quick reference for a busy health planning session. It also guides health workers to
refer and quickly obtain information. Section 2 provides country background, helping the health workers
and health program mangers to develop strategic and operational health plans that are relevant to local
situations in Southern Sudan. Section 3 outlines the goal, objectives and the principles of the Southern
Sudan health policy that are incorporated into the BPHS. It also links BPHS to referral health services and
to activities of other sectors whose positive outcomes result in prevention of disease and improvement of
health.
Section 4 presents the components of BPHS, specifying services integrated into priority actions and
clustered four areas, (i) Integrated Reproductive Health Care (IRHC), (ii) Community Based Health and
Nutrition Care (CBHNC), with emphasis on child health and nutrition , (iii) Health Education and
Promotion (HEP). Section 5 presents the Norms and Standards of service provision and management,
presenting the service packages and standards in short narratives and summarizing them in matrices for
ease of reference. Section 6 Presents the Management and Administrative Arrangements, summarizing
stewardship and oversight issues and providing guidelines for monitoring and evaluation (M/E). This
should enable the State and County Health Authorities to provide effective technical support to all
agencies providing and coordinating service delivery. It also facilitates and timely easy reporting for all
health activities from community to state levels.
9
2. COUNTRY BACKGROUND
2.1. Land and People
The Comprehensive Peace Agreement of January 9, 2005 created a decentralized structure of government
in which there are three levels of political governance in Sudan. These are the Government of National
Unity(GNU), the Government of Southern Sudan (GoSS) and the State Governments. The information
included in this section is a summary of the geographical position, administrative structure, a short
overview on the ethnic and cultural diversity and a summary of the health status in Southern Sudan to
help the health workers to link the essential packages with the priority health problems.
Southern Sudan covers approximately 640,000 square kilometers (km 2), and lies between 250 to 300 east
longitude and 40 to 120 north latitude. It boarders Ethiopia to the East, Kenya and Uganda to the South,
the Democratic republic of Congo to the South West and the Central African Republic to the West, and
therefore lies within the Meningococcal belt of the African Continent. Southern Sudan is divided into ten
states1 79 counties and 514 administrative Payams and 2,159 Bomas. The latter comprise clusters of
households or villages which form the smallest formal administrative units. Southern Sudan has widely
contrasting terrain with vast low lying plains that easily flood during the long rainy season between April
and November of each year and Mountainous area to the north and to the west that easily drain after rains.
Southern Sudan is traversed by many rivers and streams. Significantly large areas of the country are
swampy marshland or become flooded in the rainy seasons. This forms a rich ecosystem for a number of
human parasites and vectors that cause serious disease. The road network in Southern Sudan is poorly
developed and transportation is further made worse by the terrain and the climatic features. This seriously
constrains referral in cases of medical emergency and as such needs a fairly comprehensive PHC.
The population of Southern Sudan is estimated at 9,480,000 and expected to increase to 12 million by
2010 owing to high rate of natural growth and the return of refugees from neighboring countries and
internally displaced populations located in Northern Sudan. There are 300 ethnic groups in southern
Sudan. Centrally, eastwards and to a significant proportion of the South, the predominant culture is
nomadic pastoralist, but there are significant sedentary farming groups. Moreover, sedentary practices are
increasingly emerging with resettlement after the protracted war. Thus Southern Sudan has wide variation
in cultural beliefs and traditional practices on the one hand and a rapid transition through affluence, a
factor that has significant health implications. Southern Sudan is one of the poorest countries in the world,
although prospects of oil revenue promise future economic improvement. With few exceptions,
population density is low, presenting some serious constraints in the distribution of health care personnel
and commodities.
2.2. State of Health and Health Services in Southern Sudanese
According to the Sudan Household Health Survey (SHHS) of 2006, the infant mortality rate in Southern
Sudan is 102/1,000 live births and the under-five mortality rate is 135/1,000 live births, being the highest
in the world. Child malnutrition is endemic, 32.98% of under-fives are underweight, 13.5% of them
severely, another 22.04%, have moderate and 7.25% severe wasting; and Only 17.03% of under-fives are
fully immunized. The Southern Sudan Household Health Survey (SSHHS) of 2006 estimated maternal
1
Western Equatoria, Central Equatoria, Eastern Equatoria, Northern Bahr el Ghazal, Western Bahr el Ghazal,
Lakes, Warrap, Jonglei, Unity and Upper Nile.
10
mortality ratio (MMR) at 2054/100,000 live births. The antenatal care attendance rate is very low. Only
16.4% of all expectant women attend at least one antenatal care from a health professional. Moreover,
only 31.73% of mothers receive at least two doses of tetanus toxoid vaccine during pregnancy. All these
lead to a high maternal mortality ratio of 2054/100,000 live births. Less than half (48%) of people in
South Sudan use improved drinking water, and only 6.4% of the population uses sanitary means of
excreta disposal.
A range of rare ‘tropical’ diseases remain endemic in Southern Sudan under the name ‘neglected
diseases’. HIV prevalence estimates from location-specific surveys range from 0-8% among adults, but
the available information suggests that adult prevalence in significant number of areas has exceeded 1%
and continues to increase. The annual incidence of tuberculosis in South Sudan is estimated at 325 per
100,000 populations, among the highest rates in the world.
United Nations (UN) agencies and Non Governmental Organizations (NGOs) played key roles in health
service provision in Southern Sudan over the latter period of the war. The interventions focused on firstlevel health services that typify humanitarian action. Such service provision approach was inherited by
the GoSS-MoH as it was all that existed in Southern Sudan. As a result, the overall access to health care
remains below 25% of the population, with user rates estimated to be as low as 0.2 contacts per person
per year. Traditional medicine is practiced either out of conviction or because no other means of care are
available and private for-profit sector is minimal and do not play a big role in health service delivery and
is unlikely to do so in the near future.
Overall access to sustained quality health care is poor, with very few communities living within the reach
the most basic health services. The material resources and managerial expertise for administering the
sector are insufficient and largely dependent on external financial and technical assistance. Existing
health infrastructure and equipment are extremely poor, with many hospitals and health centers either
dilapidated or only have the capacity and characteristics of lower-level facilities. In addition, the facilities
are unequally distributed among the regions. On average, in rural areas, there are about 14,000 people per
health unit and 75,000 per health center. There are about 400,000 people per hospital; a recent inventory
of hospitals in South Sudan describes a heavy, largely derelict infrastructure. Less than 10% of children
under the age of five years have access to immunization services. Indeed most immunization services are
still provided by mobile teams at outreach posts. Among the expectant mothers, only 23.11% of
expectant mothers receive antenatal care from skilled health personnel and only 13.6% deliver in health
institution where only 10.02 % are cared for by skilled health personnel. Contraceptive Prevalence Rate
(CPR) stands at a 3.5% only.
At present, MoH has certain advantages and opportunities for strengthening management and restoring
services: The official launch of the “Health Policy for the Government of Southern Sudan 2007-2011” in
December 2007 and the building on the cumulative policies and strategies since 1997 coupled with more
effective partnership among the health authorities and international partners, provide a strong foundation
upon which a modern sector-wide health care delivery system can be developed. This document provides
guidelines for development of the Basic Package of Health Services (BPHS) for the delivery of essential
health interventions from the household level to the PHCC level, with managerial and technical support
from the State MoH and the County Health Department and the referral hospitals. It also provides the
opportunity for planning and developing critical infrastructure from which basic and comprehensive
Emergency Obstetric and Neonatal Care (EmONC) and Integrated Essential Child Health Care/
Integrated Management of Childhood Illnesses (IECHC/IMCI) can be made readily accessible to mothers
and children. Once this is achieved, the services for adolescents and adults are easily added as the most
essential requirements to deliver them are already provided for, by the maternal and child health services
thereby providing universal access to health care.
11
3. BASIC PACKAGE OF HEALTH SERVICES (BPHS)
3.1. Overview
The last two decades have seen the emergence of a significant number of low cost technologies and
approaches to support the effective delivery of PHC in the remotest of locations of the world. Southern
Sudan missed the opportunity to join with the rest of the world in the adoption of such technologies and
approaches because of a prolonged war and struggle for justice. Following the signing of CPA, a MultiDonor Trust Fund (MDTF) was set up to channel resources to stimulate growth and development both in
the Northern and Southern Sudan. Within this framework, the Umbrella Program for Health Systems
Development (UPHSD) was established to develop core health sector systems and capabilities and
increase population access to basic health services. BPHS is the service delivery components of UPHSD.
3.2. The Purpose of BPHS
The BPHS is the medium term strategy to implement the health policy of the GoSS. It is a guide that
enables providers to plan integrated and holistic health services from the community level to the
Comprehensive Emergency Obstetric and Neonatal Care Primary Health Care Center (CEmONCPHCC)
level and link them to a rational hierarchical referral system because health problems of individuals and
communities are often multiple. It also enables the development of comprehensive continuum of
preventive health care organized in life-cycle order from conception to old age. The document provides a
means to establish good organization, logistics and competent staffing that are prerequisite to successful
performance. The BPHS will help individual professionals to assess their own capabilities against the
service norms and standards for each level of care and the competency required to deliver them
effectively, and become an incentive for continued education. The document helps service managers and
health worker trainers to identify skill and knowledge requirements and gauge it against performance to
develop more effective oversight, support and training curricula training curricula to update the
capabilities of health staffs. Other professional tasks not directly related to individual patient care but
necessary for quality and aesthetics to improve the health of their local communities are included to help
health service managers define support needed for provision of quality primary health care.
The BPHS comprises a selection of interventions for diseases prevention and health promotion,
rehabilitation and selected curative services that address priority health problems integrated in a way that
makes it accessible at appropriate levels of care at affordable cost to:
• Improve maternal and child health
• Control communicable diseases
• Improve of community nutrition, especially mothers and children
• Control the most common non communicable diseases.
The term Basic Package of Health Services (BPHS) is used to refer to the PHC component of health
services that is part of a comprehensive package of care continuum in Southern Sudan. It is synonymous
to essential health service package (EHSP) or minimum packages of health services (MPHS). The BPHS
is linked to the referral health services and to activities of other sectors that are are relevant to preventive
promotive health care, such as Agriculture, Education, Environmental Management, Gender, Social
Welfare, Culture and Religious Affairs, that contribute directly to health outcomes, thereby creating
opportunities for collaboration in planning and service delivery to mutually synergize and enhance the
progress towards MDGs.
12
3.2.1. The Goal
The Basic Package of Health Services (BPHS) contributes to the GoSS-Health Policy goal of “Promotion
of equitable access to essential health services. The intention is to strengthen health systems while scaling
up efficient, effective and sustainable provision of health services to attain rapid reduction in burden of
disease thereby reducing poverty among the people of South Sudan.”
3.2.2. The Objectives
1.
2.
To increase access to PHC services from 25% to 50% by 2010.
To improve the quality of care through the delivery of specified norms and standards of
services.
3. To strengthen the management of health services through capacity strengthening for State
Ministries of Health, County Health Departments, and Payam Health Departments
3.2.3. The Values and Principles
The Basic Package of Health Services ascribes to the values of the GoSS health policy of, the right to
health equity, pro-poor, community ownership, good stewardship and good governance. The principles of
BPHS are: community participation, enhanced first level care, strengthened rational referral services and
intersectoral collaboration.
3.2.3.1. Community Participation
Community members are to be empowered to take greater responsibility for their health. They are to be
sensitized to identify their health priorities, mobilize, allocate and manage locally available resources to
carry health activities that they are technically competent to implement, monitor and evaluate with
support from community based extension service agents from health and collaborating sectors.
3.2.3.2. Enhanced first level care
Essential health services must be available within the reach of the population. At community level,
maternal and child health workers (MCHW) and household health promoters (HHHP), working under the
direct supervision of Village Midwives (VMW) and community health workers (CHW), attached to a
primary health care units (PHCU), with support from community health extension workers (CHEWs) and
village healthy committees, will support household members in implementing selected simple and
effective health interventions.
3.2.3.3. Strengthened referral system
Provision of the BPHS is backed by services from the County, State and the teaching Hospitals, together
with those of the State and Central Public Health Laboratories to cater for clients with more serious or
relatively rare health needs. County hospitals and are responsible for oversight, technical support and
capacity strengthening especially in diagnostic and curative related services at household, PHCUs and
PHCCs. The County Health Departments (CHDs) are responsible for all community based health
activities within communities. CHD and hospital staffs are therefore all members of the county health
management teams (CHMT). This is to ensure rational referral and that hospital-based resources
strengthen the delivery of BPHS.
3.2.3.4. Intersectoral collaboration
BPHS recognizes the importance of all the sectors in improvement of health and encourage joint
implementation of development initiatives that impact the health of people in Southern Sudan.
13
4. COMPONENTS OF THE BASIC PACKAGE OF HEALTH SERVICE
4.1. Overview
The basic package of health services (BPHS) provides the service norms for four levels of care, Village
level Health Care, Primary Health Care Unit (PHCU), Primary Health Care Centre (PHCC) and County
Health Department (CHD). This section of the document defines the roles and describes the services to
help in the planning, acquisition of essential equipment and commodities, and to put in place the
organization and logistics required for effective delivery of services. The BPHS will deliver four service
components. Services for each component in turn address the most urgent health priorities (those that
result in the highest numbers of deaths and disability) and management systems to support helath
intervention initiatives, clustered as follows:
1.
2.
3.
4.
Integrated Reproductive Health Care
Community Based Health and Nutrition Care
Health Education and Promotion
Management, Oversight, Monitoring and Evaluation
Specific programs have been developed by the different directorates in GoSS-MoH based on
comprehensive policies, operational guidelines, procedures and protocols to ensure the quality services
under their respective mandates. These services are integrated into the care elements and services to be
delivered through BPHS. For each of the service areas, a summary description is provided that explains
the tenets of the proposed services and the expected targets of the medium term health strategies and
responses.
This section links BPHS with strategies proposed by the different directorates of GoSS-MoH to keep
PHC and other health initiatives and activities in tandem.
4.2. Integrated Reproductive Health Services (IRHS)
Integrated Reproductive Health Services (IRHS) are established to maintain “reproductive health through
informed choices of gendered, safe, reproductive and sexual practices.” The services include Essontial
Obstetric Care (EOC), Women’s Reproductive Health Services (WRHS), Adolescent Sexual and
Reproductive Health Services (ASRH) and Men’s Reproductive Health Services (MRHS).
4.2.1. Essential Obstetric Care (EOC)
The Southern Sudan Household Health Survey (SSHHS) of 2006 estimated maternal mortality ratio
(MMR) at 2054/100,000 live births. Given the current estimated population of 9.7 million and a rate of
natural growth of approximately 4%, this translates to severe complications in 76,000 young Southern
Sudanese mothers during pregnancy and child birth, with close to 10,600 dying every year. For each of
these mothers, the risk of their baby dying within the first year of life is three times that of other babies.
Yet the causes of these deaths are nearly all preventable. Because of this the GoSS has highly prioritized
maternal and child health. Preventive and promotive maternal and child health services are therefore the
centerpiece of PHC services and the BPHS. Essential Obstetric Care in Southern Sudan is modeled
around establishment of readily accessible quality Emergency Obstetric and Neonatal Care. EmONC is a
focused care approach during pregnancy, delivery and in the postpartum period. The objective of
EmONC is to reduce maternal mortality ratio (MMR) by 20% to 1630 per 100,000 live births by 2010
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and by a further 20% by the beginning of 2012 to less than 1300 per 100,000 live births. This will be done
by increasing the number of women delivering in health facilities and overseen by skilled birth attendants
from 14.75% to 20% by 2010 and to 30% by 2012. In order to achieve this, the number of health facilities
will be developed to raise the access to basic and comprehensive EmONC from the current 13.6% by
20% (to 36.6%) in 2010 and by a further 20% to (56.6%) by 2012. EmONC comprises the minimum
initial service package (MISP) for Reproductive Health (RH) and emergency preparedness and response.
The EmONC services include: (i) counseling for early identification of pregnancy, seeking and
compliance with antenatal care; (ii) focused antenatal care based on the principles of standard obstetric
care (SOC), which aims at early initiation of antenatal care and attendance of at least 4 antenatal care
sessions by all mothers. This should enable early identify and referral of high risk pregnancies for
management by skilled health professionals; (iii) nutrition education and support for expectant and
postnatal mothers, (iv) Skilled care and hygienic handling for mothers and newborns by skilled birth
attendants (SBA) at delivery based on EmONC principles (v) early identification, provision of life saving
first aid measures and rational referral for life threatening complications, i.e. antenatal hemorrhage,
infections and severe hypertensive-renal disorders in pregnancy; (vi) focused postnatal care to prevent
complications or identify any complications early by critically observing the mothers at least once at 6hrs,
in 6 days, after 6 weeks and at six months (the four sixes), checking especially for post partum bleeding
and or sepsis, starting life saving management and referring the mother and child promptly for further
treatment; (vii) Post abortion care (PAC) to minimize mortality and prevent severe morbidity as a result
of inevitable or incomplete abortions; and (viii) Prevention of mother to child transmission (PMTCT) of
STI and HIV, and nutrition education and support for lactating mothers; (ix) Newborn care that aims to
prevent the risk of death from hypothermia especially for the newborns with low birth weight and
choking; baby friendly initiatives, i.e., prevention of pre-lacteal feeds, early initiation of breastfeeding and
encouragement of exclusive breastfeeding ; identification of malformations, convulsive disorders or other
obvious developmental anomalies and referral for treatment.
4.2.2. Family Planning and Women’s Health (FP/WH)
Family planning and women’s health (FP/WH) is an initiative based on women’s reproductive health
rights (RHR). The objective of is to increase the percentage of women in their reproductive years using
effective methods of contraception from the current 1.73% to 3% by 2010 and to 8% by 2012. Service
elements are: (i) awareness raising on FP to empower women and men to practice conception by
informed FP choices; (ii) provision of appropriate choices of effective FP methods to enable delay in
initiation of child bearing for girls and birth spacing for women who have established child bearing to
allow full recovery of health in between pregnancies and to minimize grand multi-parity (iii) create
awareness and provide screening for and management of obstetric fistula; (iv) training in self palpation
skills for masses in the breast and seeking examination or referral; (v) encouragement to regularly attend
clinics for Pap smear, provider initiated counseling and testing (PICT) for HIV, (vii) promotion of
tetanus toxoid (TT) vaccination for Women of Reproductive Age (WRA); and (iv) condom programming
for protected sex and syndromic management of STI (SMSTI) and mass communiation to promote
voluntary counseling and testing (VCT).
4.2.3. Adolescent Sexual Reproductive Health Services (ASRHS)
ASRHS will provide services for adolescents and young people to prevent sexually transmitted infections,
adolescent pregnancies and HIV/AIDS. Youth friendly service provision and care will be adopted to
encourage health seeking behavior among young people. The goal is to increase RH awareness and
Reproductive Rights knowledge among the youth to 90% by 2011. Service elements include: (i) Gender
and Sexuality education; (ii) ABC promotion; (iii) VCT/PICT; and (iv) SMSTI.
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4.2.4. Men’s Reproductive Health Services (MRHS)
MRHS will promote safe sexual practices and raise awareness on reproductive organ diseases of men.
The service elements are: (i) Promotion of equitable gender roles in family health care; (ii) Promotion of
VCT/PICT; (iii) reduction of sexual partners and condom use; (iv) SMSTI; and (v) Awareness raising and
referral for suspected prostate cancer and enlarged prostrate.
4.3. Integrated Essential Child Health Care (IECHC)
Southern Sudan currently has the highest child mortality rate in the world. The mean IMR was estimate in
the SSHHS 0f 2006 at 102/1,000 live births, while the CMR or under five mortality rate (U-5MR) was
135/1,000 live births. The rate of generalized acute malnutrition (GAM) is 33%, with only 21% mothers
exclusively breastfeeding their children fox six months. The same survey showed that only 43% of all
under fives were fully immunized.
Integrated essential child health care (IECHC) is a term that incorporates “the global integrated
management of childhood diseases (IMCI),” while approaching the child survival and development issues
from a health perspective. It is an approach that is includes all the technical aspects of IMCI but
emphasizes focus on the well child and disease prevention. The aim is to improve child survival and
development. The objective of IECH in Southern Sudan is to reduce child mortality rate by 25% by the
year 2011. The interventions to achieve these objectives are integrated in BPHS under the following
specific service norms:
4.3.1. Community Based Child Survival Program (CBCSP)
This is a mix of community level actions that address the most common childhood illness by promoting
preventive measures, recognizing signs of illness in children early and treating them safely while
observing for danger signs and other reasons for referral to the PHCUs, PHCCs or hospitals for more
technical assessment and appropriate treatment promptly. The program will deliver behavior change
communication on nutrition, growth monitoring and prevention, home treatment of malaria, diarrhea and
recognition and referral of pneumonia, through a network of community based providers trained in the
competent use of simple algorithms to assess, classify (assign) and treat the ill children, while counseling
mothers, fathers and other caregivers in child health seeking behavior. This will be carried out under the
oversight of CHEWS.
Community based child survival package will include but not be limited to (i) prevention and treatment of
malaria, (ii) prevention and treatment of diarrhea, (iii) management of acute respiratory infection (ARI)
and pneumonia, (iv) mass campaigns for immunization, (v) community based growth monitoring and
promotion,(vi) home management of mild malnutrition, vitamin A supplementation and periodic mass
treatment for worms, (vii) referral of children with severe malnutrition and complications or those with
malnutrition not responding to appropriate community based rehabilitation to TFCs.
4.3.2. Expanded Program on Immunization (EPI)
The program target is to raise access to routine immunization (as measured by DPT3 coverage) from the
current less than 10% to 30% by 2008 and to 80% by 2011; however, all the coverage for all the other
antigens will be monitored as well with the aim of attaining “herd immunity” that is 80% or more
coverage by 2011. This will be attained through routine immunization of children daily in all PHCC,
monthly immunization of children in PHCUs and other designated sites by mobile outreach teams, mass
immunization on acceleration days and NIDs and mop up immunization activities.
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4.3.3. Essential Nutrition Action (ENA)
The target of ENA is to reduce severe malnutrition from its baseline levels by 30% at the end of 2009 and
by 50% by 2011. This program is an initiative to primarily prevent malnutrition, but includes very
specific measures for resuscitation and rehabilitation of children who are severely malnourished. The
services include (i) the promotion of exclusive breast-feeding for at least the first 6 months of life and
provision of complementary feeding with continued breastfeeding for at least 24 months, (ii) growth
monitoring and promotion (iii) micronutrient supplementation and community based nutrition
rehabilitation for children with mild to moderate malnutrition; (iv) provision of treatment and
rehabilitation for children who get severe malnutrition, with complications at designated Theraputic
Feeding Centers (TFCs).
4.3.4. Home treatment of Malaria, Diarrhoea and Pneumonia
In Southern Sudan, Malaria accounts for 20% to 40% of all consultations at outpatient departments and
between one in every five (1/5) and one in every four (1/4) deaths. Deaths are especially common among
children under the age of five years, pregnant women and people from areas where malaria transmission
is seasonal. Diarrhea and other enteric infections are common in Southern Sudan because of poor
sanitation and use of surface water or water from unprotected sources. As in all countries with high CMR,
it is estimated that diarrhea associated deaths account for between one in five (1/5) to one in three (1/3) of
childhood deaths. Reduction of the period of breast feeding and early introduction of weaning foods
(before six months) that tend to set in with affluence significantly increase the diarrhea morbidity and the
risks of deaths from severe dehydration change in infant feeding and weaning practices. Acute
respiratory infection (ARI) is frequent in children in Southern Sudan. There is currently little or no
accurate data on the frequency of occurrence of ARI, but on the average children get infected once every
one or two months. The severe and dangerous form of ARI is acute lower respiratory tract infection
(ALRI) or pneumonia. Like diarrhea, pneumonia is a common cause of childhood deaths in Southern
Sudan especially in children under the age of five years. It is much more common in the colder highlands
climates than in the warm lowlands. Pneumonia occurs more commonly in children that are weaned at an
early age, or those that suffer from malnutrition as a result of complications of other infections such as
malaria and the vaccine preventable disease. More over a large number of children will also suffer from
pneumonia as a direct complication of measles and other vaccine preventable infections. Vitamin A
deficiency also increases the risk of all the three infections pneumonia and the risk of dying from the
vaccine preventable childhood infections. Another cause of pneumonia is keeping children in smoky
places. Protein energy malnutrition (PEM) and micronutrient deficiency especially vitamin A and zinc,
aggravate the severity of infections and increase the risks of deaths in childhood.
4.4. Management of endemic Common Endemic Diseases (MCED)
The most common endemic communicable diseases in Southern Sudan are Malaria, diarrhea, enteric
infections and worm infestations, acute respiratory infections (ARI) and tuberculosis (TB). Other
common health problems are visual, especially infections such as trachoma and refractive errors and other
eye problems among children. Southern Sudan also lies along the meningococcal belt of the African
Continent and outbreaks tend to occur at the beginning of dry season. South Sudan is now exposed to the
human immunodeficiency virus (HIV) infection and the acquired immune deficiency syndrome (AIDS)
pandemic and all efforts need to be made to prevent the epidemic taking root in the country.
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4.4.1. Malaria
Malaria is transmitted throughout the year in the swampy lowlands. In all other areas incidence of Malaria
increases during rainy or flooding seasons as well as in association with movement of populations with
little immunity to endemic areas when outbreaks occur or the disease reaches epidemic proportion. Since
malaria is among the top leading contributors to the burden of diseases, the Ministry has established a
special Roll Back Malaria program within the Directorate of Preventive Health. The program has 8 set
objectives that are integrated into the BPHS under the following service norms:
4.4.1.1. Prevention
The objective is: to increase population coverage with effective malaria prevention as part of an integrated
vector control strategy that utilizes all approaches including long lasting insecticidal nets, indoor residual
spraying and environmental management when and where most suitable and sustainable.
The targets are: (i) Sixty per cent (60%) of children under the age of five sleep under LLITN, (ii) seventy
(70%) of households have one or more LLITN, (ii) Sixty per cent (60%) of pregnant women sleep under
LLITN, (iii) Eighty per cent (80%) of structures in target areas are sprayed with quality indoor residual
spraying (IRS)
The services are: (i) Mass distribution of LLITNS, (ii) distribution of LLTNS through ANC,
immunization clinics and (iii) mass spraying of living structures.
4.4.1.2. Case management
The objective is: to provide wide access to diagnosis and highly efficacious artemisinin-based
combination therapy to all affected by malaria using a mix of approaches that include public and private
health care providers, a trained and supervised commercial sector and community distribution.
The targets: (i) Sixty per cent (60% ) of children under the age of five with fever receive ACT within 24
hours, (ii) Sixty per cent (60%) of patients with uncomplicated malaria attending health facilities receive
correct diagnosis (iii) to identify signs of very severe disease timely, give pre-referral treatment (oral
ACT for those who can swallow and retain, rectal Artesunate suppositories for those who cannot swallow
or retain and anticonvulsant – diazepam- for patients who have fits) and refer promptly in 90% of cases.
The services are: (i) Use of algorithms for assessment, assignment and treatment of children under the
age of five promptly with appropriate (ACT) at community- home management of malaria (HMM) within
24hrs, to minimize delay in initiation of treatment, (ii) early detection of sings of malaria prompt
confirmation of diagnosis of malaria and treatment for older children and adults at PHCU/PHCC and (iii)
recognition of danger signs of malaria, referral and prompt initiation of second line treatment with
quinine.
4.4.1.3. Malaria in Pregnancy
The objective is : To deliver a package consisting of ITN, IPT and effective treatment to pregnant women
through comprehensive and focused antenatal care services involving all levels of health care including
the communities.
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The targets for M/E are: (i) Reach sixty per cent (60%) of all pregnant women with ANC services with 2
or more doses of intermittent preventive treatment (IPT), (ii) sixty per cent (60%) of expectant mothers
sleep under LLTNs,
The services include: (i) counseling of mothers to attend ANC and get at least two (2) doses of IPT, (ii)
early detection of fever in pregnant mothers, test for malaria at PHCU/PHCC and provision of treatment
with appropriate medicines, (iii) complementary distribution of IPT through community based maternal
health workers or midwives and (iv) detection and treatment of anemia.
4.4.1.5. IEC, Social Mobilization and Advocacy
The objectives is: To mobilize all sectors of society to promote malaria control and increase adoption of
positive behavior, based on a comprehensive malaria communications strategy that includes all available
media and communication channels.
Targets for M/E are: (i) At least 80% of responsible members of families know the effects, signs and
symptoms of malaria, importance of prompt and complete treatment with the effective artemisinin-based
bases combination treatment (ACT),(ii) Eighty per cent (80%) of health service providers sensitize and
advise their clients (patients) on malaria prevention , early detection and treatment of cases at each health
service session.
The services are: (i) Awareness creation on malaria and its effects, (ii) promotion of acquisition and on
sleeping under LLITNs, ANC and IPT, use of simple algorithms for home management of mamlria for
children under the age of five year by household health promoters (iii) compliance counseling for proper
use of LLTNs.
4.4.2. Diarrhea, enteric infections and infestations
In Southern Sudan, enteric infections are still common and cholera epidemics occur from time to time
especially during the changes from dry to wet seasons and vice versa. During such periods dysentery
caused by bacteria, amoeba or flagellate infections also tend to increase.
The service elements for management of enteric infections include (i) raising community awareness on
the causes of diarrhea and its prevention. Mothers are to be encouraged to continue with the healthy infant
feeding and weaning practices, (ii) Training communities on safe use of potable water and promotion of
hand washing before and after handling food, after toilet including after cleaning or handling children’s
feces; (iii) raising awareness on safe disposal of feces including those of children; (iv) promoting
immunization especially against measles (v) and regular administration of vitamin A (every six months)
for all children under the age of five; (vi) all parents and other people who care for children are to be
taught to (a) recognize outbreaks of diarrhea early and immediately alert staff at PHCU or PHCC.
Additional gastro enteric infection and infestation related services are regular deworming of children
through periodic mass campaigns and school health programs; and health education of recognition of
other enteric infections especially abdominal pain, progressive fever and generalized weakness,
constipation or small loose stools that signify typhoid fever. Such are to be referred to PHCC for
laboratory investigation, diagnosis, treatment with antibiotics and are to be reported to the payam and
county health authorities.
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Other services for prevention of diarrhea directed to communities are: (i) awareness raising and
sensitization workshops for village development committees - participatory health and sanitation
(PHAST) training for community health workers and maternal child health workers. Facilitation for
practical identification of water points, their protection and discouragement of risky sanitary practices by
identifying them and developing community based interventions. Emergency preparedness by identifying
early warning signs for outbreaks of diarrhea and developing responses and reporting. Construction of
demonstration toilets and protection of water sources in schools, market places and administration
centers, and any other strategic places such as community gathering venues.
4.4.3. Acute Respiratory Infection (ARI)
Older people with pneumonia must be referred promptly to the PHCU to start treatment with oral
antibiotics immediately and further to PHCC for treatment with antibiotics injections and oxygen if
respiratory failure sets in. Report cases of pneumonia accurately every week.
4.4.4. Tuberculosis
Although, the exact burden of Tuberculosis in Southern Sudan remains unclear, it is a major cause of
morbidity and mortality. The estimated incidence of new sputum smear positive TB cases is 101 per
100,000 Population and 228 per 100,000 Population for all TB forms. With an estimated population
of 9.7 million people in 2007, this translates accordingly to 9,797 new sputum smear positive TB
cases and 22,116 TB cases of all forms occurring every year. TB mortality is estimated at 65 per
100,000.
This situation is likely to be worsened by the cropping HIV epidemic which from limited surveys is
already standing at 1% to 7% in the general population with border towns close to some Sub-Saharan
African Countries such as Uganda, Kenya, Ethiopia, Democratic Republic of Congo (DRC), Central
African Republic having high prevalence rates compared to the interior of the Country. The HIV
sero-prevalence among TB patients indicate that 11.2% of the TB patients are co-infected with HIV
with higher prevalence been noted in Nzara (50% HIV prevalence among TB patients, Nimule (25%
HIV prevalence among TB patients), Yei (14% HIV prevalence among TB patients) and Rumbek
(10% HIV prevalence among TB patients). HIV fuels the prevalence of the TB epidemic by
promoting the rapid progression of recent and latent mycobacterium tuberculosis infection into active
disease, and increasing the rate of recurrent TB. TB in people living with HIV/AIDS pose a greater
risk of increased transmission of tuberculosis in the community, on the other hand, TB has a
profound effect on the course of HIV/AIDS infection because it accelerates the process of transit
from asymptomatic HIV to AIDS Related Complex (ARC) or to overt AIDS.
The overall goal of the TB program to contribute to the improvement of the quality of life of
the people of Southern Sudan by reducing dramatically the burden of the TB in Southern
Sudan in line with the Millennium Development Goals and Stop TB Partnership Targets
The objectives are:
(i)
to expand the DOTS coverage to 100% by the end of 2013 without compromising
the quality of case detection and treatment, integrating it into the BHSP,
(ii)
(ii) to raise the number of tuberculosis cases detected from 1,562 cases in 2005 to
7,000 smear positive cases by 2013 while maintaining cure rate at 85%,
(iii)
(iii) to prevent emergence of drug resistant tuberculosis and monitor TB resistant
patterns in Southern Sudan and
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(iv)
(iv) to enable and promote operational research.
The service elements are
(a) Continue the expansion of the TB treatment centers to reach the level of one center per
100,000 people by integrating the centers in the PHCCs as they get established, to improve
patients’ access to effective diagnostic and treatment services. This requires high political
commitment with sustained financing to the tuberculosis control in Southern Sudan
(b) Promotion of effective community involvement in tuberculosis and patient centered care
through advocacy, communication and social mobilization,
(c) Ensure that all laboratories in Southern Sudan submit TB slides for quality control to
ensure effective TB microscopy,
(d) Ensure that all treatment centers use standard treatment regimen and are regularly
supervised and patients supported,
(e) Ensure that all TB treatment centers have regular supply of TB drugs and
(f) Ensure that 100% of the TB treatment centers receive regular and effective supervision
and monitoring from all levels of government and impact assessment is done.
4.4.5 Guinea Worm Disease.
Southern Sudan harbors over 80% of the global caseload for guinea worm disease. It is a parasitic disease
endemic in the poorest of the poor of the rural populations lacking access to safe water compounded with
ignorance. The disease affects individuals who drink water from contaminated unsafe water source by an
infected person with the disease. With an incubation period ranging from 9 – 12 months, the infected
person who has ingested Cyclops (vector) presents with the symptoms and signs of the disease. The pain
caused by the guinea worm’s emergence typically occurs during planting and harvesting seasons. It
prevents many people from working or attending school for as long as 2 to 3 months. In heavily burdened
agricultural villages, fewer people are able to tend their fields or livestock, resulting in food shortages,
interference with education and loss of income that can run into millions of dollars. The Ministry of
Health government of southern Sudan is committed to support the global Campaign targeting the
eradication of guinea worm disease in southern Sudan by the end of 2009. The eradication measures
include a mechanism to mobilized communities and training of community agents ( village volunteers) to
undertake community-based surveillance activities at the village level, providing care to individuals with
active infection with guinea worm disease, promotion of drinking only water from underground protected
sources free from contamination, such as boreholes or protected hand-dug wells, Encouraging persons
with emerging guinea worms not to enter ponds or other surface wells that people may use for drinking
water. Distribution and promotion of use of water filters (i.e., fine-mesh cloth filters like nylon, to remove
the Guinea worm-containing water fleas).Treatment of water sources with an approved larvicide such as
abate, that kills water fleas, without posing a great risk to humans or other wildlife and providing
communities with new safe sources of drinking water, and training them to maintain or repair existing
ones.
4.4.6. Sexually Transmitted Infections (STI), Human Immunodeficiency Virus infection and Acquired
Immunodeficiency Syndrome (HIV/AIDS)
Sexually transmitted diseases are a common cause for illness in health facilities in Southern Sudan. In
Lakes State for example, STI feature as the fifth most common cause of illness as see in health facilities.
Moreover, a recent report from IRC has shown that out of 125 clients who came for treatment in a clinic
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in Rumbek with STI complaints 10 were confirmed to have syphilis (8%). Another organization that
supports health clinics around Yei has reported an average of 600 clients coming for STI services per
month.
There is still very limited data on the prevalence of HIV infection and AIDS in Southern Sudan. It is
believed, however, that the incidence and prevalence of HIV in Southern Sudan are lower than in
neighboring countries, because it was protected by the restricted labor migration and trade which could
accelerate HIV transmission, during the two-decade-long civil war. Epidemiologically, Southern Sudan
could be the last untouched pocket of HIV transmission in Africa. However, the country faces a massive
threat from HIV by following factors: i) it is surrounded by countries with high HIV prevalence, ii) it has
up to four million displaced people, some living in high prevalence countries in the region and will be
returning home, iii) has high levels of poverty, low school enrolment, a rudimentary health system, and
iv) its women and girls have low status in the society. So far data from different sources which include
counseling and testing centers, maternal health services centers that offer prevention of mother to child
transmission of HIV (PMTCT) and TB treatment centers indicate that HIV/AIDS epidemic has reached a
low generalized phase. Data from the ANC clinics extrapolated to the whole population indicates an HIV
prevalence rate of 3.1%. while data from counseling and testing in the TB clinics in Southern Sudan
indicated HIV prevalence of 17% of TB patients in Nzara, 14% in Yei, 10% in Rumbek and 25% in
Nimule giving an average prevalence HIV in 8% of all cases of TB.
The approach to STI and HIV/AIDS are aimed at ensuring adequate access to integrated prevention,
treatment, care and support for all especially marginalized populations. This entails the creation of a
supportive environment for a sustainable and effective response to HIV/AIDS in communities of
Southern Sudan, In addition the BPHS will enhance the HIV/AIDS program efforts to scale up
comprehensive HIV/AIDS care and treatment and ensure equitable access to services for all especially the
vulnerable populations and expand access to comprehensive adherence counseling, psycho-social support
and care for PLWHA. Special programs will target specific populations at risksuch as sex workers,
adolescents, long-distance truck drivers, uniformed services and prisoners. The service elements include,
(i) awareness creation on the causes, risk factors complications and dangers of STI and HIV/AIDS, (ii)
Promotion of safer sexual behavior including condom promotion, procurement and distribution, (iii)
encouragement of prompt health care-seeking behavior in case of experiencing symptoms and signs of
STI, (iv) comprehensive case management of STI at PHCU and PHCC, (v) Prevention and care of
congenital syphilis and neonatal conjunctivitis, (vi) promotion of provider initiated counseling and testing
(PITC), (vii) referral linkage with HIV testing and other HIV/AIDS prevention, treatment and care
services, as appropriate and (viii) home based care and adherence counseling for PLWHA already on
treatment
4.4.7. Neglected Tropical Diseases (NTD)
The Ministry of Health (MoH) of the Government of Southern Sudan (GoSS) recognizes NTDs as a
major obstacle in improving the health of the people of Southern Sudan. At least twelve NTDs are known
to be endemic in Southern Sudan and lead to additional disease burden with significant health and
economic consequences. For example some 5,400 communities and over four million people are known
to be at risk of river blindness , schistosomiasis, also known as snail fever, is second only to malaria as the most
devastating parasitic disease in tropical countries with and estimated 200 million people in 74 countries (100 million
in Africa alone). Most NTDs have previously been targeted only by intermittent control through short-term
donor funded programs and were limited to control, elimination or eradication activities that only target
onchocerciasis, trachoma, and guinea worm infections.
The community based component of BPHS enhances the new Southern Sudan integrated NTD control
program aimed at expansion of activities that target lymphatic filariasis (LF), onchocerciasis,
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schistosomiasis, soil-transmitted helminthiasis (STH), and trachoma. The service lements include (i)
health education to create awareness on the causes, dangers and impact and means of prevention of the
diseases, (ii) promotion of interventions to reduce the contact of people with the paracites or their vectors
(carrying agents), through provision of protected water sources, provision of fuel woodaway from known
breeding sites of vectors, encouragement of construction and proper use of toilets or avoidance of water
sources by all especially those who are infected and (iii) preventive chemotherapy through mass drug
administration (MDA) and other complementary approaches recommended by the WHO. Briefly the
actual activities are:
•
Schistosomiasis Control Initiative (SCI)that include prevention of transmission with a single, annual
dose of the drug praziquantel, mass treatment with albendazole, identification and treatment of cases with
albendazole and health education to increase number and use of toilets.
•
Onchocerciasis Control Initiatives (OCI) that encompasses the mapping of Loa loa using
RAPLOA method and sustainable community-directed distribution systems and mass
administration of ivermectin ; and elimination of the blackfly through insecticide spraying.
•
RAAB and trachoma mapping, community distribution of topical antibiotics for mass treatment
and the visual health program (see the visual health section below)
4.4.8. Primary Eye Care and Visual Health
The visual health program is part of the vision 2030, which in Southern Sudan aims at prevention of
avoidable blinding diseases that contribute 75% of the blindness, namely: cataract, corneal scarring
diseases including trachoma and vitamin A deficiency, onchocerciasis, refractive errors and low vision and
childhood blindness. It is estimated that close to 4% of people aged 5 years and above suffer from
significant blindness and the average prevalence of active trachoma (TF in children aged 1-9) ranges
between 15%-87%. Overall it has been estimated that 3.9 million people need antibiotic treatment and
that up to 206,000 people are in need of immediate surgery to correct the scaring that results from
trachoma (trichiasis) Visual health can be maintained through simple preventive approaches. The service
elements include: (i) health education and awareness on the types and causes of eye diseases and
promotion of eye health, (ii) prevention of eye infections through regular washing of face, (iii)
management of common and simple eye diseases especially distribution of topical antibiotics for
treatment of epidemic eye infection during outbreak seasons, (iii) Detection and referral of treatable
blindness including cataract and corneal opacities or trichiasis, (iv) training school teachers in visual
acuity testing and referral and outreach mass testing in schools to detect children suffering from refraction
errors, (v) training in simple lid eversion and the removal of sub-tarsal foreign bodies, (vi) Irrigation of
the eye for chemical injuries, (vii) referral of cases that need more complicated treatment to county eye
clinics, (viii) community based mass distribution campaigns for antibiotics for trachoma and OV
preventions commodities including water filters (and) outreach trachoma trichiasis surgeries and cataract
extraction and provision of lenses.
4.4.9. Oral Health
Oral health is a state of being free from chronic mouth and facial pain, oral and throat cancer, oral sores,
birth defects such as cleft lip and palate, periodontal (gum) disease, tooth decay and tooth loss, and other
diseases and disorders that affect the oral cavity. Risk factors for oral diseases include unhealthy diet,
tobacco use, harmful alcohol use, and poor oral hygiene. Efforts are to be made to expediently embrace
the “WHO Global Oral Health Program (ORH)”, whose objectives are reoriented to development of
policies in oral health promotion and oral disease prevention and coordinated with similar priority
programs of “Chronic Disease and Health Promotion (CHP)”. The approach is to empower communities
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to develop and implement demonstration projects with focus on disadvantaged groups according to the
PHC concept. The elements of oral health component of CBHC include (i) creation of awareness on oral
health and promotion of self-care oral hygiene practices through brushing and effective control of diet to
minimize nutrition risk factors for dental diseases, (ii) child focused oral health education and prevention
aimed at getting better dental status in the future generation through brushing sessions at schools, Mobile
outreach for screening and simple treatment or referral for complicated cases including cranio-facial
development diseases or suspected oral cancers , (iii) integration of safe water and sanitation programs
with implementation of effective appropriate fluoride programs (florination or deflorination) for
prevention of dental caries, (iv) intregration of the WHO global strategies on diet, physical activity and
health and discouragement of tobacco use (smoking and smokeless tobacco) to reduce risk factors to oral
cancer, oral mucosal lesions and periodontal disease.
4.4.10. Mental health
The WHO defines mental health as a state of well-being in which every individual realizes his or her own
potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to
make a contribution to her or his community.
Globally, neuropsychiatric disorders (NPDs) are estimated to contribute 14% of all diseases burden.
NPDs contribute to higher rates of morbidity among the non-communicable diseases (NCDs). This is
significantly more than heart disease, stroke and cancer. Depression, alcohol and substance use disorders,
and psychoses cause significant chronic disability, yet their true burden is underestimated because of
inadequate appreciation of the connection between mental disorders and other health conditions.
Depression can be treated effectively in low- and middle-income countries with low-cost antidepressants
or psychological interventions such as interpersonal therapy. When delivered in primary care, the
interventions are as cost effective as antiretroviral drugs for HIV/AIDS. In addition family focused
psychosocial interventions are effective for the management of schizophrenia and other psychoneurotic
disorders. Service elements for mental health include (i) awareness creation at community level on mental
disorders and their manifestations in local settings (ii) support for parents of infant with mental
impairment, (iii) school-based interventions, such as teacher to pupil counseling, peer to peer counseling,
identification and referral of children with poor school progress, counseling and referral of children with
“new” onset deterioration in class (iv) workplace and unemployment counseling programs for youths and
adults, (v) activity programs for elderly people (vi) abatement of domestic violence and street related
aberrant behavior, substance abuse, home and school truancy and gender related violence (vii)
interventions to develop assertiveness, self-reliance and appropriate participation, which are in turn
components of mental health e.g, ‘gender equitable rights training” as an integrated component of
programs for prevention of HIV infection
4.4.11. Community based prevention and care for common injuries and rehabilitation
Injury is a very common cause for ill health and a significant number result in death or disa bility from
injuries that could have been helped by first aid. A large number of injuries can be prevented by simple
measures, starting from awareness of risk factors in the homes, and in the surrounding environment. More
recently, motor vehicle associated injuries have increased to alarming rates. First aid skills can save lives
and reduce injury, but it’s vital that people are prepared to deal with injuries when they happen. First aid
is easy to learn, and everyone can and should have basic first aid knowledge. The care given before
emergency medical help is available can literally mean the difference between life and death. For
example, a blocked airway can kill someone in three to four minutes. So a simple procedure such as
opening someone's airway can save their life while they're waiting or being transferred for more skilled
help. Similarly while a high level of specialized care for people with disability is too ambitious for the
24
BPHS at this stage, many simple things can be done at primary health care level to prevent and manage
disability.
The care for people with injury and community based rehabilitation for people with chronic debilitating
conditions comprise the following service elements, (i) identification and awareness creation on the most
common local injuries and envenomations (ii) preparedness for early and ongoing treatment of accidents,
including mass accidents and injuries to prevent unnecessary deaths or disabling complications, (iii)
provide basic specific advice and care for people affected by disability or potentially disabling conditions
(leprosy, TB spine, trachoma, cerebral malaria, etc) (iv) define and maintain referral procedures for
specialized or specific services (eye surgery, prosthetics, etc), (v) provide simple basic assistive devices
(toilet chairs, crutches, etc), either locally produced or sourced from specialized organizations, (vi)
identify people with functional (physical and mental) impairments at early stages for timely referral and
(vii) maintain surveillance of disabilities among of the area’s population.
4.5. Integrated Disease Surveillance and Response (IDSR)
For some key conditions, reliance on the monthly or quarterly reports of the HMIS is not sufficient as
they may be notifiable diseases, or subject to epidemic. The IDSR is a separate, but related, reporting
system which enables more frequent monitoring of cases of a limited range of disease falling into four
categories:
• Diseases of epidemic potential, e.g., meningitis, cholera,
• Diseases targeted for eradication, e.g., measles, polio
• Diseases targeted for elimination, e.g., Guinea worm disease
• Diseases of major public health significance, e.g., malaria, childhood diarrhea and pneumonia and
tuberculosis
Through monitoring of activity levels, an appropriate and rapid response can be put in place if it appears
that an outbreak or epidemic is developing. However, all figures are then fed back to the HMIS for
routine planning purposes.
4.6. Health Education and Promotion
Health promotion is a new approach to improvement of health and social status, prevention of disease and
disability. It is a paradigm shift from provision of information, education and communication (IEC) alone.
It is led by BCC, but in addition includes facilitation of behavior change by providing inputs that enable
and reward the behavior change. Health promotion works through concrete and effective community
action in setting priorities, making decisions, planning strategies and implementing them to achieve better
health. At the heart of this process is the empowerment of communities for ownership and control of their
own endeavors and destinies. The process draws on existing human and material resources in the
community to enhance self-help and social support, and to develop flexible systems for strengthening
public participation in health care. This entails continuous provision of support for personal and social
development through providing information and education for health. It involves enhancement of life
skills to increases the options available to people to exercise more control over their own health and their
environments, and subsequently enable them to make choices conducive to improved health status.
In Southern Sudan, Health Promotion aims at increasing awareness and demand for essential health
services, with major focus on prevention of disease and promotion of health. It also addresses the
emerging or new morbidities that have serious public health consequences i.e., STI and HIV/AIDS,
trauma and related disability. The approach is to facilitate learning throughout life cycles, in order to
prepare people to respond appropriately to their health needs and those of children. Schools and other
25
education facilities and networks provide strategic entry points to improvement of health within the
schools and institutions, which can then be transmitted to the home, work place, administrative, cultural
and recreation venues. Efforts are to be made to integrate service development and delivery for the health,
education, agriculture, communication, gender, social, culture and religious affairs sectors facilitate
pooled synergism in the improvement of health and nutritional status of the people. Health professionals
and their respective counterparts in other sectors are to work together towards a health care system which
contributes to the pursuit of health and social advancement. This moves the role of health sector beyond
responsibility for providing clinical and curative and preventive services only. Captive audience including
schools, women, youth and men’s economic and social groups should be engaged as partners in the joint
initiatives in this process of learning for transformation. The BPHS in each state should develop protocols
for community based health promotion services that embrace the already established regional strategies of
lead health development agencies, the WHO, UNFPA, UNICEF and World Bank. The following are
summary description of some of the programs:
4.6.1. The Promotion of health seeking behavior - targeting epidemiological priorities
All health workers should always create awareness and sensitize individuals and communities about the
priority health problems, their prevention and care. The aim is to create demand for the cost effective
services. The service elements will include (i) awareness creation and counseling during home visits, (ii)
advice and counseling during visits to facilities, (iii) social mobilization for uptake of preventive primitive
health services during health acceleration days and during the international consciousness or memorial
days (iv) production and distribution of written health education and promotion materials including
posters, fliers and other published materials that disseminate health messages. In addition, all acceleration
or mop up days will be accompanied by health education and social mobilization messages. Behavior
change Communication to support compliance to ANC, immunization, GMP, possession of sleeping
under LLTNS, use of water from protected sources, avoidance of fast running streams and use of water
filters and water-guards, safe sexual and reproductive and prevention of STI and HIV/AIDS . These
messages will be timed to ensure focus at the most appropriate time for each problem, including periods
of most likely epidemic outbreak.
4.6.2. Basic package of health and nutrition for Schools
Basic education has the highest potential for instilling a lasting societal change, therefore schools will be
used as entry points into the communities to open channels between the health sector and broader social,
political, economic and physical environmental sectors. The “Basic Package for School Health (BPSH),”
which was developed by UNICEF and WHO will serve as a standard guideline in all schools. The
objectives are to maintain optimal health of school pupils, to induce health and survival instinct in the
new generations, and to transfer the benefits of healthy school life to the homes, villages and future
generations. Adolescents should benefit from knowledge about reproductive health and rights in
preparation for healthy reproductive lives.
Demonstrations for safe water sources, toilets, house ventilations, kitchens, and play grounds are to
prioritize schools to ensure the sustained improvement of health of most school children while passing
health messages to the surrounding communities. Health messages can be passed through school
exercises, e.g., young and lower grade learners can be given reading exercises that promote health seeking
practices such as taking infants for immunization and growth monitoring, keeping infants under LLINs,
making under-fives sleep under bed nets, and reinforcing staple diets with high protein supplements.
Schools drama, participatory educational theatres (PET), folk music and first aid contests are to be
organized to facilitate as participatory education and learning process. School letters to parents should
26
also be used to pass health messages. School health inspection and growth monitoring outreach should be
carr5ied out regularly by school health teams to monitor and evaluate the outcome of the initiatives.
4.6.3. Community based nutrition and food security program (CBNFSP)
CBNFSP will address food production, preservation, preparation and dietary practices in close
collaboration with the ministries of agriculture, water, environment, education, gender, social services,
culture and religious affairs. Actions and specific responsibilities will be assigned to the CORPS, sector
extension workers and the county health service managers to plan and implement productive projects.
Captive groups that include women, youth, farmers’ groups and schools will be sensitized and provided
with necessary inputs for farming, animal and poultry production in sufficient quantities to bridge the
gaps in their food sufficiency,.
Women will be taught income generation skills and opportunities for benefiting from microfinance skills.
They will also be trained storage of grains and pulses and methods of preservation of perishable foods
such as vegetables, milk and meat, that are appropriate o their local situations including value addition
where possible, Community groups will be facilitated to invest in low level technologies and other
methods of food production and preservation that they are willing to adopt and invest in. Demonstration
farms will range from ever green kitchen gardens to large mechanized farms depending on the willingness
of communities to invest. In schools the aims will be to have farms that will not only make the schools
food sufficient, but also to be a source of extra income. The demonstration projects will be used as forums
for training in nutrition and dietetics, construction of safe and energy conserving kitchens and appropriate
food granaries. Such farms should be large enough to interest the grandaunts in commercial food
production, including fish farming.
4.6.4. Community management of environmental health and hygiene (CMEH)
CMEH should create awareness and provide skills training in protection of their water sources, promotion
of use and construction of toilets, and over and above this they will be exposed to education on personal
hygiene. The programs will include education in physical safety, accident and snake-bite prevention and
first aid, promotion of oral health and community based mental health programs. Under the theme
“Healthy people in healthy places,” the places where people live, work, learn, and play will protect and
promote their health and safety, especially those at greater risk of health disparities. At household level
CMEH will promote health through safe and healthy home environments, with a focus on equitable
gender role assignment and responsibility for health; in particular, the empowerment of men to be more
involved in the health and social well being of their families. At community level CMEH aims to increase
the number of communities to be protected, and promote better health and safety and prevent illness and
injury in all their members. In schools, the UNICEF Package of Health for Schools model will be adopted
and delivered to increase the number of schools that protect and promote better health, safety and
development of all pupils and staff.
At work place, CMEH will develop Healthy Workplaces activities to promote and protect the health and
safety of people at work by preventing workplace-related fatalities, illnesses, injuries, and
personal health risks. These will include gender relationships and perspectives at work place
using STI and HIV/AIDS as entry points. Training in prevention and first aid for physical injuries
and snake-bite are highly relevant to the situation in Southern Sudan. Other work place
interventions will target lifestyle related diseases including obesity, high blood pressure and
diabetes. Healthy healthcare settings are absolutely essential to successful health promotion
programs. Again, HIV/AIDS as one of the health workplace programs will be useful entry points.
27
Health promotion will be largely a community based affair, but will be supported by health talks and the
construction of demonstration for safe living environments prioritizing water sources, toilets, sanitary
residential and work place surroundings, well ventilated houses to minimize respiratory infections, safe
kitchens, food storage, nutrition and dietetics and cookery, safe snacking foods, safe housing, LLINs and
how to use them in local circumstances, kitchen gardens and household demonstration farms, fish ponds,
poultry farms and zero grazing.
4.7. Monitoring and evaluation
Monitoring and evaluation (M/E) are essential in order to provide a basis for assessing and improving
performance, and to feed through into strengthened planning and management. M/E will take place
through a variety of mechanisms, to be integrated across BPHS components as far as possible. The M/E
activities will be carried out by the Directorate of Research Planning and Health Systems Development
which is responsible for its activities budget.
4.7.1. Health Management Information System (HMIS)
The primary mechanisms for monitoring progress with BPHS implementation will be the situation
analyses for future County Health Plans (CHPs), and the Health Management Information System. A
newly designed HMIS is to be rolled out in 2009, and training for health workers is to be carried out by
all implementing partners. All of the indicators selected for inclusion will serve to monitor BPHS activity
levels and impact. A gap in the new HMIS is that there is currently no comprehensive or co-ordinated
reporting of community-based activities and these are to be developed as soon as BPHS implementation
starts. At present, activities which take place at this level – whether community-based, such as outreach
from health facilities, such as immunization – are aggregated and reported on the same registers and
formats as health centre activities. For effective monitoring of epidemiological data, coverage, and
logistics at the community level, a separate format is required to reflect the contents of the community
level BPHS.
4.7.2. Periodic M/E
Periodic, as opposed to routine, M/E will take place through the existing surveys such as the
Demographic and Household Survey, and specific surveys as need arise. With a strengthened HMIS and
better routine performance monitoring, the need for such surveys is expected to reduce. Better use of the
research unit within MOH, and more frequent review and analysis of existing documents can do much to
provide updated information on how the system and the services are performing.
28
4.7.3. Operational research
The bulk of health problems and health systems challenges in developing countries lie at the primary
level. A significant number of these require operational research to establish causalities and
consequences. Much operational research currently takes place in Southern Sudan, both initiated
from within the country and from outside. However, there is no existing mechanism for “quality
control” to ensure reliable evidence and no existing forum for disseminating findings and for
ensuring that findings filter through into improved policy and practice. The GoSS-MoH has
established a Directorate of Research, Planning and Health System Development (DRPHSD) which
is responsible for operations research. This should inform planning to ensure cost-effectiveness and
attainment of objectives. The BPHS lead agents, together with the research unit within the DRPHSD,
will work together to coordinate and housing proposals and study reports, with an improved database
of research-related activities relevant to each state whether the proposals originate from within or
outside Southern Sudan.
29
Table1. BPHS at a Glance
Component
Integrated
Reproductive
Health Services
Sub-components
Essential Obstetric Care
(SOC, EmONC,PAC,
PMTCT,PNC, FP)
Protective SRH for women
Adolescent SRH
Men’s SRH
Community
Based Health
Care
Integrated Essential Child
Health Care
Management of local endemic
diseases
Community based prevention,
care for common injuries and
rehabilitation
Visual health, Oral Health
and Mental Health
Health
Promotion
Disease surveillance and
emergency preparedness
Awareness sensitization and
BCC on the priority health
problems
School Health and Nutrition
Community based nutrition
and food security
M/E and
Operations
Research
Community actions for safe
environment, water and
sanitation
Routine Health Management
Information System, Periodic
Surveys and special studies
Service Norms
Quality focused antenatal, safe hygienic delivery and post natal care emphasizing early recognition of complications,
life saving interventions appropriate to each level and expedient rational referral; PMTCT and prevention and
management of STI in pregnancy. Maternal and Newborn Nutrition. The PHCCs are of two types BEmONC PHCC
provides the signal functions of basic EmONC: (i) I.V antibiotics administered, (ii) I.V oxytoxics administered, (iii) I.V
Anti-convulsants, (iv) Manual Removal of the placenta, (v) Assisted delivery by Vacuum Extraction, (vi) Manual
Vacuum Aspiration (MVA) of retained products of conception and post Abortion Care (PAC), (vii) Neonatal
Resuscitation; and comprehensive EmONC which provides the full EmONC functions including surgical obstetrics.
Safe temporary and emergency contraception permanent contraception, management of obstetric fistula, infertility,
prevention and management of STI and HIV/AIDS screening for and early treatment for cervical and breast cancer;
empowerment for gender equitable reproductive practices; and childhood female reproductive (physical) anomalies.
Empower young people and provide services that enable them make reproductive and sexual decisions that will ensure
their health now and in the future by preventing adolescent pregnancies, STI, HIV/AIDS and secondary infertility.
Gender equitable roles training, and promotion of ABC.
Counseling on gender equitable sexual roles, shared responsibilities regarding male involvement in to know and act to
improve women’s health and participate in contraception; recognition and management of men’s RH problems in
Childhood, physical anomalies, adolescence delayed or disturbed puberty and adults sexual dysfunction, infertility,
prevention and management of STIs and HIV/AIDS and gender based violence and in Old Age, PADAM (Partial
Androgen Deficiency in Aging Male) and prostatic hypertrophy.
Expanded Program on Immunization (EPI) - Achieve and maintain coverage with all the vaccines currently available
for preventable childhood illnesses according to GAVI guidelines.
Essential Child Nutrition Action: Promotion of exclusive breast feeding for six months starting with initiation of
breastfeeding within 30mins to 1hour of birth, starting complementary feeding from seventh month and continue breast
feeding for 24 months. Growth monitoring and promotion and micronutrient supplementation and community based
nutrition rehabilitation, referral of unexplained failure to thrive and severe malnutrition.
IECHC, an integrated approach to managing common childhood illnesses - Malaria, Childhood diarrhea, Acute
respiratory infections (ARIs) Pneumonia, anemia, malnutrition, intestinal parasites and common epidemic outbreaks.
This combines the Communty Based Child Survival Program(CBSP) and Integrated Management of Childhood
Illnesses (IMCI); and care of special children – those with anomalies and developmental impairment.
Preventive services and IEC on Malaria, Diarrhea ARI and Pneumonia, TB, STI and HIV/AIDS, meningitis and
enteric infections.
Case management: provision of treatment for common endemic illness as close to the population as possible.
Empower communities to prevent and provide appropriate immediate care for injuries including rational referral and
identify and care for people with various physical and functional impairment and chronic debilitating conditions
integrating them in as near normal community life as possible.
Visual health: school based eye care programs, face washing sessions for younger children, health education and
training of teachers on visual acuity testing and simple remedial measures for RE mass topical antibiotic treatment as
and when necessary.
Oral Health: School based programs, train teachers on sessions for brushing and inspection for cavities for the young
children. Oral health education and checkups at PHCU and PHCCs
Mental health: Psychosocial programs for stressful conditions, awareness raising, community based counseling and
community programs for gender based violence, substance and alcohol abuse, and behavioral counseling and referral
for serious psychiatric conditions.
Community based identification and reporting of known disease outbreaks: meningitis, cholera, trachoma,
staphylococcal conjunctivitis; recognition of unusual outbreaks and community disasters preparedness and response
Maternal care, IECHC, Endemic common infective diseases, community based environmental safety, injury prevention
and first aid, safe water use and sanitary practices, reproductive practices and sexual behavior.
Skill based training on physical injury, drowning, accident and snake-bite prevention and management
as entry point to intersectoral integrated development promotion: information, education and behavior change
communication for health and food security Community based nutrition and food security program: Food production,
preservation, preparation and dietary practices and hunger prevention
Gender perspectives of health and development: Skill based adolescent reproductive health
Empower communities to develop a range of environmentally friendly and sustainable, collective community actions for
production, exchange, preservation, storage, of a range of food that ensure prevention of hunger and preservation of
optimal nutritional status of female and male children and adults
Development of community capacities to gain sustained access to improved water supply and sanitation services and
promotion of safe hygienic practices (to include education about use of latrines, hand-washing with soap and water
and clean water sources).
Ensuring shared responsibility for collection and interpretation of health related information, data, statistics or
experiential studies. Extending the routine health data/statics collection from state to community based level to inform
planning and evaluation of programs.
30
31
Table2. Summary of Integrated Reproductive Health Care (IRHC) 1.
Emergency Obstetric and Neonatal Care (EmOMNC)
Service
Focused
Antenatal
Care
Care of
uncomplicated
Delivery
Emergency
Obstetric and
Neonatal care
Focused
Postnatal Care
Village level
Primary Health Care UNIT (PHCU)
1. Identification of
pregnant mothers and
counseling for Early
initiation and compliance
with ANC, and referral
for antenatal care, PMTCT
and STI prevention and
treatment
3. Nutrition counseling,
for mothers, micronutrient
supplementation iron, and
folic acid and vitamin A.
5. Malaria prevention,
LLINs and IPT
6. Preparation and timely
referral for BEmONC or
CEmONC according to
risk status including
arrangements for
residential waiting homes
As at Village level plus:
1. Identification and referral of high frisk
cases or complications to appropriate
EMNOC centre:
High Risk/Complications: CPD, fluid
retention, previous C/section, multiple
pregnancy and grand multiparity,
antepartum hemorrhage, severe edema,
severe antepartum fits : refer to
CEmONC PHCC.
Referral of all mothers in
labor to BEmONC PHCC
for clean hygienic
assistance of
uncomplicated delivery.
Clean hygienic assistance
of delivery for precipitous
labor, while transferring to
PHCU/PHCC
Awareness raising on and
identification of high risk
labor
CPD and other obstructed
labor, Hemorrhages,
Fever, Convulsions – refer
to CEmONCPHCC.
Provision of Clean hygienic assistance of
uncomplicated delivery for abrupt labor,
oral misoprostol (or cytotec),
Clean hygienic assistance of
uncomplicated delivery: gloves,
cotton wool, clean blade, soap, oral
misprostone-cytotec,
Obstructed labor and Haemorrhage:
refer to CEmONC PHCC
Comprehensive non surgical and surgical
obstetric services 24hrs.
Identification of hemorrhage and
stabilize with ORS for volume
replacement as case is transferred to
refer to CEmONCPHCC;
Transfer of obstructed labor, eclampsia,
high fever and sick neonates to EmONC
centres.
The signal Functions of Basic
EMoNC:
I.V antibiotics administered
I.V Oxytoxics administered
I.V Anti-convulsants
Manual Removal of the placenta
Assisted delivery by Vacuum
Extraction
Manual Vacuum Aspiration of
retained products of conception
Neonatal Resuscitation
The signal Functions of Comprehensive
EmONC:
IV antibiotics administered
I.V Oxytoxics administered
I.V Anti-convulsants
Manual Removal of the placenta
Assisted delivery by Vacuum Extraction
Manual Vacuum Aspiration of retained
products of conception
Neonatal Resuscitation
Surgical obstetrics : Cesarean section
and emergency hysterectomy
1.Maternal and IECHC
counseling Referral for
PNC and Child Health
Clinics
2.Identification, treatment
and immediate referral:
a. To CEmONCPHCC:
Postpartum
hemorrhage/inevitable or
incomplete abortion
Volume replacement with
ORS, MVA and
misoprostol
b. To BEmONCPHCC:
Infection: Cotrimoxazole
Pallor: Iron, Folate and
Multivitamins
Convulsion: Clear airway,
oral sedative
1.Maternal and IECH care counseling
Referral for PNC and Child Health
Clinics
2.Identification, treatment and
immediate referral
To County Hospital:
Postpartum hemorrhage/
inevitable or incomplete abortion
Volume replacement with ORS,
MVA and misprostone
To PHCC:
Infection: Cotrimoxazole
Pallor: Iron, Folate and
Multivitamins
Convulsion: Clear airway, Sedate
1.Counseling Referral for PNC and
Child Health Clinics
2.Immediate treatment for Puerperal
complications:
(i) Postpartum hemorrhage/
inevitable or incomplete abortion
Volume replacement with IV
fluids,
MVA/PAC and parenteral
oxytocics
or oral misoprostol
(ii) Infection:
Parenteral antibiotics
(iii) Anaemia: Iron, folate and/or
referral
Convulsion: Clear airway, iv
anticonvulsants
1.Counseling Referral for PNC and Child
Health Clinics at PHCC and PHCUs
2.Immediate treatment for Puerperal
complications:
(i) Postpartum hemorrhage/
inevitable or incomplete abortion
Volume replacement with IV fluids,
MVA/PAC and parenteral oxytocics,
oral or intravaginal misoprostol
(ii) Infection:
Parenteral antibiotics
(iii) Anaemia: Iron, folate and/or
referral
Convulsion: Clear airway, iv
anticonvulsants
2. Moderate risk, infection, Post partum
hemorrhage: Volume replacement –
ORS
Infection: Cotrimoxazole
Pallor: Iron, folate and multivitamins,
HBP, Refer to BEmONC PHCC.
BEmONC Primary Health Care
Centre (PHCC)
Services provided 8 hours daily all
working days a week.
All activities PHCU level plus:
Services at CEmONC Primary Health
Care Centre (PHCC)
Services provided 8 hours daily all
working days a week.
All activities of BEmONC plus:
1. Liaisons with a Reproductive
health focal point
1. Liaisons with a reproductive health
focal point
2. All signal functions of Basic
EmONC.
2. All signal functions of Comprehensive
EmONC (at antenatal Preparation)
- normal deliveries
- treatment of moderate obstetric
complications including i.v.,
antibiotics, MVA and PAC
3. Identification of high risk cases
and referral to CEmONC or State
Referral Hospital.
4. Monthly Antenatal care Mobile Clinic
services.
32
Table3. Summary of Integrated Reproductive Health Care (CERH2) – Preventive Reproductive Health
Services (PRHS)
Service
Services within villages
Services at Primary Health Care
UNIT (PHCU)
Services at BEmONC Primary
Health Care Centre (PHCC)
Services at CEmONC Primary
Health Care Centre (PHCC)
Family
Planning and
Reproductive
Women’s
Health
Services
Awareness creation for demand
generation for WRH and
counseling of women and their
sexual partners to accept FP/WH
services.
CBD of oral FP methods,
Condom promotion and supply
Daily Counseling of women and their
sexual partners to accept FP/WH
services.
Provision of oral FP methods,
Condom promotion and supply.
Plus Monthly outreach:
BP check, SMSTI, VCT
Pap Smear, LT contraceptives-IUD
and Sc implants Palpation for breast
masses by quarterly appointments
Daily Counseling of women and
their sexual partners to accept
FP/WH services.
Provision of oral FP methods,
Condom promotion and supply.
BP check, SMSTI, VCT
Pap Smear, LT contraceptives-IUD
and Sc implants Palpation for breast
masses by quarterly appointments.
Daily Counseling of women and
their sexual partners to accept
FP/WH services.
Provision of oral FP methods,
Condom promotion and supply.
BP check, SMSTI, VCT
Pap Smear, LT contraceptives-IUD
and Sc implants Palpation for breast
masses by quarterly appointments.
Surgical male and female
contraception
Adolescent
SRH and
Young People
Counseling on sexuality and
ABC
Promotion of VCT and SMSTI.
In school counseling
Out of school - youth groups
social marketing
Youth focused services: CT, SMSTI
and counseling for ABC.
Condom supply
Daily service at specified time
Provision of Youth focused services
daily service at specified time:
VCT, SMSTI and counseling for
ABC.
Condom supply
Youth Friendly Services, focus on
sexual and reproductive health
interventions and special attention
for pregnant teenagers.
Men’s RH
Advocacy for gender equitable
sexual roles.
Counseling and referral for CT
and SMSTI.
Social marketing of condoms
Awareness creation on male
reproductive organ disorders,
urethral stricture, prostate
hypertrophy and cancer and
testicular cancer.
Counseling for gender equitable
sexual roles, CT and SMSTI.
Condom distribution
Identification and referral for male
reproductive organ disorders, urethral
stricture, enlargement of and cancer
of prostate and testicular cancer.
Counseling for gender equitable
sexual roles,
VCT and SMSTI, Social marketing
of condoms
Identification and referral for male
reproductive organ disorders,
urethral stricture, prostate
hypertrophy and cancer and
testicular cancer.
Case identification and referral
Limited care on male reproductive
organ disorders, urethral stricture,
Outreach surgery for prostatic
hypertrophy
Referral for all prostatic and
testicular cancer.
33
Table4. Summary of CBHC1 - Integrated Essential Child Health Care
Service
Promote EPI among parents
Identify under-five immunization defaulters,
counsel and refer
Prepare and mobilize communities to attend
Mass outreach/mobile immunization or during
NIDs.
Surveillance and reporting of cases of Vaccine
preventable diseases
Services at Primary Health Care
UNIT (PHCU)
Monthly routine outreach/ mobile
immunization at static centers
Counsel referred under-five
immunization defaulters and immunize,
Prepare and mobilize communities to
attend Mass immunization on NIDs.
Surveillance and reporting of cases of
Vaccine preventable diseases
Services at Primary Health Care Center
(PHCC)
Daily routine immunization, six days a
week
Counsel referred under-five immunization
defaulters and immunize,
Prepare and mobilize communities to
attend Mass immunization on NIDs.
Surveillance and reporting of cases of
Vaccine preventable diseases
1.Baby friendly initiatives: Counseling on
prevention of pre-lacteal feeding, exclusive
breast feeding for first six month timely and
early weaning and continued feeding for 24
months,
2.Community based GMP and Counseling and
training/demonstrations in diet rich in protein
and calories by selection and enrichment of
local weaning diet.
3.MUAC screening and supplementary feeding
for moderate malnutrition and for children in
families of at risk child. Referral of severe
malnutrition To TFC
4.Mass de-worming and Micronutrient
supplementation on NIDs.
1.Baby friendly initiatives: Counseling
on prevention of pre-lacteal feeding,
exclusive breast feeding for first six
month timely and early weaning and
continued feeding for 24 months,
2.Community based GMP and
Counseling and training/demonstrations
in diet rich in protein and calories by
selection and enrichment of local
weaning diet.
3. GMP malnutrition and for children in
families of at risk child. Referral of
severe malnutrition To TFC
4.Mass de-worming and Micronutrient
supplementation on NIDs.
1.Baby friendly initiatives: Counseling on
prevention of pre-lacteal feeding, exclusive
breast feeding for first six month timely
and early weaning and continued feeding
for 24 months,
2. GMP and counseling and
training/demonstrations in diet rich in
protein and calories by selection and
enrichment of local weaning diet.
3. Nutrition rehabilitation protocol for the
mild to moderately malnourished children.
5. Treatment of severe malnutrition at
designated TFCs
Integrated
Community Based Child Survival Program
Management
1. Awareness and promotion of ITNs on NIDS
and Mass distribution days.
2. Train CBHWs (Community midwives,
CHWs and MCHWs) on simple use of
algorithms to assess classify and assign
treatment or refer cases of HMM (treatment of
uncomplicated fever with ACT.
3. Referral of children with danger sings to
PHCCs: Severely clod body, severely hot body,
inability or refusal to feed, fast berathing, skin
pinch returns very slowly
1. Algorithm guided treatment of
Malaria with ACT or second line
treatment.
2. Algorithm guided treatment of
moderate dehydration from diarrhea
with ORS, and severe dehydration or
diarrhea with danger sings with IV
ringers solution. Use of zinc and other
micronutrient supplement,
encouragement of increased frequency
of feeding during and post diarrhea.
1. Algorithm guided treatment of Malaria
with ACT or second line treatment.
2. Algorithm guided treatment of moderate
dehydration from diarrhea with ORS, and
severe dehydration or diarrhea with danger
sings with IV ringers solution. Use of zinc
and other micronutrient supplement,
encouragement of increased frequency of
feeding during and post diarrhea.
Expanded
program on
immunization
Essential
Nutrition
Action
of childhood
illness
Services at Community
2. HMD - Awareness on recognition of diarrhea
and promotion and training of CBHWs and
parents on use of ORS, zinc supplement,
encouragement of increased frequency of
feeding during and post diarrhea.
3. HMARI. Training parents on recognition of
pneumonia by counting number of breaths per
minute and in chest indrawing and early
treatment with cotrimoxazole for cases of
cough, rapid breathing in drawing of chest and
nasal flaring. Encouragement of increased
frequent feeding during and post ARI.
4. Sedation for cases of convulsion and referral
for first time convulsion.
3. Algorithm guided treatment
pneumonia by counting number of
breaths per minute and in chest indrawing nasal flaring with parenteral
antibiotics- amoxicillin and provision of
moist oxygen .
4. Sedation for cases of convulsion and
referral for first time convulsion.
6. Epidemic and outbreak management cholera and meningitis, measles,
whooping cough, polio yellow fever, RV
fever etc.
3. Algorithm guided treatment pneumonia
by counting number of breaths per minute
and in chest in-drawing nasal flaring with
parenteral antibiotics- amoxicillin and
provision of moist oxygen .
4. Sedation for cases of convulsion and
referral for first time convulsion.
6. Epidemic and outbreak management cholera and meningitis, measles, whooping
cough, polio yellow fever, RV fever etc.
7. Coordination of activities including.
6. Encouragement of Isolation of sick children
and quarantine for children during epidemic
outbreaks of cholera and meningitis.
34
5. SERVICE NORMS AND STANDARDS BY LEVELS OF CARE
5.1. Overview
The service norms and standards are marched with the requirement of the health policy as much as
possible. Based on discussions respective groups and based on the strategies developed by different
programs, the best practices from neighboring counties have been adapted practices Southern Sudan
Health policy and the realities of manageable human resource (HR) norms. This is proposed to match
with service delivery standards and maintain quality of care. Partner health service organizations are
encouraged to aim at the higher service norms where possible.
The services are summarized by level in matrices at the end of the section to facilitate the acquisition of
the correct equipment and standardize supplies.
5.2. Village Level.
At the village level, care is provided by Home health Promoters (HHP), and Mother and Child Health
Workers (MCHHW) under the direct supervision of “Community Midwives” and senior CHW and
periodic Supervision of “Community Health Extension Workers (CHEWS)”. Home Health Promoters
(HHPs) are elected by the community members and trained as community health workers for a minimum
of nine months. Literacy is an advantage, but not mandatory. HHPs are not intended to be full-time
professionals of the health system and as such receive no salary, but are motivated through other material
and non-material incentives. HHPs should be residents in the community they serve and committed to
serve all residents without distinction. Their key functions include, (i) health education and promotion (ii)
dispensing of household level preventive health commodities such as condoms and water-guard
(chemicals), water filters and the limited number of medications allowed for household level use for
prompt treatment especially of children, which include, co-trimoxazole, ORS/zinc and ACT, (iii) active
case finding of pregnant women and referral for Antenatal care attention (iv) active case finding and
treatment and guidance for children with diarrhea, ARI and fever; and referral of severe cases or those
that have developed complications, (v) enumerating cases and keeping surveillance and notification of
disease, (vi) alertness to unusually high rate of any type of illness to provide early warning signals of
outbreaks of epidemic diseases.
The joint team of HHPs and MCHWs are volunteers whose incentives are determined by the communities
they serve in, with some guidance and support from the county and state health authorities. Appropriate
incentives may include ensuring a career path in health professions for the academically performing
volunteers - “in school youths” for example. The village health committees provide administrative
oversight and support. They are elected community members who should be representative of the whole
community and maintain a gender balance with equal numbers of women and men. The committees: (i)
maintain liaison between the SMoH, the service provider and the community, (ii) encourage and facilitate
community-based health development initiatives especially protection of water sources, construction of
toilets and other environmental sanitation measures, (iii) identify and propose to the CHD the candidates
to be trained as CHWs, (iv) maintain oversight over the local health services (PHCU/Cs), (iv) mobilize
communities to support PHCU/C infrastructure and maintenance. The technical supervisors are
“community health extension workers (CHEWs)” who should work in teams of four, one community
enrolled nurse, one public health technician, one community mid-wife and one nutrition field educator.
These cadres will conduct field visits where they will observe the general state of health supporting VHCs
and the home based care providers in promoting improvement of water supply, safe water use and
35
sanitary practices. They will observe and provide on the job guidance and where necessary, training for
the services listed under community level care in the BPHS.
Summary of key services at village level
Health promotion: IEC, social marketing of health domestic level preventive health commodities, and
the prescription of the allowed medications (co-trimoxazole, oral rehydration salts (ORS) / zinc and
artesunate combination therapy).
• Active case finding of pregnant women and referral for antenatal care attention.
• Active case finding and treatment and guidance for children with diarrhea, ARI and fever; and
referral of severe cases or those that have developed complications.
• Enumerating cases keeping surveillance and notification of disease, with appropriate reporting.
• They will trained to be alert to unusually high rate of any type of illness, and to provide early
warning signals of outbreaks of epidemic diseases.
Important clarification: Investment directed at reducing maternal mortality will be made in educating professional skilled midwives and
providing other health staff trained as “skilled birth attendants”. The focus will not be on training any more Traditional Birth Attendants
(TBAs), but training MCHWs, whose skills will primarily be on the compliance counseling for the promotion of preventive reproductive and
obstetric health service, with sufficient skills in prompt identification and referral of obstetric complications, and hygienic and safe
assistance of any abrupt labor on transfer. This enables the creation of career path for the MCHWs through further training to community
and professional midwifery or nursing. It is acknowledged that the training of sufficient Community Midwives will take time. Therefore in
the short term, the MCHWs and TBAs will be provided training in the selected simple reproductive health care interventions until there is a
sufficient number of trained Community Midwives to completely phase out TBAs.
5.3. Primary Health Care Units (PHCUs).
PHCUs are the frontline health facilities staffed by three health staff - two Community Health Workers
and a Community Midwife. They provide basic preventive and curative services. One of the CHWs is
primarily in charge of the curative activities and is therefore based in the PHCU, while the second is
responsible for overseeing and coordinating the community based activities implemented in collaboration
with the network of HHPs. In a long term perspective the CHW in charge of the curative aspects of the
PHCUs will be replaced by a clinical officer (CO), while the one in charge of oversight of the community
based activities will be replaced by public health officer. There should be one PHCU for every 15,000
people. Key activities of a PHCU are (i) preventive care and health promotion, (ii) antenatal care, normal
deliveries and family planning, (iii) curative care for common and uncomplicated diseases, early
identification and referral for complicated cases, (iii) case follow up and treatment of chronic diseases
diagnosed at higher level, (iv) referral to PHCC or CH for complementary exams or treatment, if
necessary, (v) first aid for trauma, stabilization and referral where necessary (vi) home treatment and
outpatient care for moderate malnutrition, follow-up patients seen and treated for severe acute
malnutrition, (vii) training activities of community based health cadres, administrative and support
activities (HMIS, maintaining registers and, if applicable, book-keeping). Once a month the PHCU should
host outreach services that will provide limited PHCC level services. These will include outreach
immunization, antenatal and family planning, water and sanitation promoters. Similarly on special
occasions, they will host other outreach services such as visual, oral health and LLTN distribution teams.
Summary of Services provided at PHCUs
•
•
•
Preventive care and health promotion
Antenatal care, normal deliveries and family planning, once trained staff is available
Curative care for common and uncomplicated diseases
36
•
•
•
•
•
•
Diagnosis and treatment of simple cases and referral of the more complicated cases, follow up
home care and compliance counseling for people with chronic diseases diagnosed at higher level
Referral to PHCC or County Hospital for further investigation or treatment where required
First aid for trauma (stabilization and referral)
Home treatment and outpatient care for moderate malnutrition, follow-up patients with severe
acute malnutrition
Training activities (of HHPs)
Administrative and support activities (HMIS, maintaining registers)
5.4. The Basic Emergency Obstetric and Neonatal Care Primary Health Care Centre
(BEmONCPHCC)
The basic EmONC (BEPHCC) are the first referral health facility, It offers a wider range of diagnostic
and curative services than a PHCU, notably laboratory diagnostics, it also has an observation ward. It
provides treatment of simple cases and 24-hour basic Emergency Obstetric and Neonatal Care (EmONC).
The PHCC is staffed qualified health professionals, including a minimum of 1 COs and 3 registered or
certified Nurse/Midwives (or Enrolled community Nurses), 3 CHWS or 2 CHW and 1 vaccinator; 2
Midwives (can temporarily be held by MCHWS; one nurse midwife, 1 laboratory assistant, one pharmacy
technician, one public health technician, two cleaners and two watchmen/ ground staff. The basic
EmONC PHCC dispenses a wider range of drugs than PHCUs, specifically they provide parenteral
treatment and minor surgical procedures. In obstetrics, they provide life saving procedures like manual
vacuum aspiration (MVA) and post abortion care (PAC). There should be one (number 1) Basic EmONC
PHCC for every 25,000 women of child bearing age i.e, a total population of 50,000 people. Key
activities of a PHCC are, (i) the signal functions of basic EmONC, i.e., i.v. antibiotics, i.v. oxytoxics, i.v.
anti-convulsants, manual removal of the placenta, assisted delivery by vacuum extraction, manual
vacuum aspiration of retained products of conception (MVA) and PAC, neonatal resuscitation, family
planning, adolescent sexual reproductive health (ASRH), child birth assistance, (ii) antenatal care (ANC),
(iii) postnatal care follow up, (vi) curative care (including parenteral administration of medicines and
fluids, (vi) stabilization care for severe malnutrition, (vii) stabilization of people with critical injuries or
illness and referral, (viii) surgery for minor trauma, and dental care, (vix) TB diagnosis and treatment
(DOTS). BEPHCC also provide screening for STIs/HIV, provision of VCT and PMTCT services and
Observation, with at least 10 beds, six of which should be obstetric beds.
Summary of key services provided at BEmONCPHCCs
• Preventive care and health promotion
• 24-hour basic Emergency Obstetric and Neonatal Care.
o I.V. antibiotics administered
o I.V. oxytoxics administered
o I.V. anti-convulsants
o Manual removal of the placenta
o Assisted delivery by Vacuum Extraction
o Manual vacuum aspiration of retained products of conception
o Neonatal resuscitation
• Curative care (including I.M. injections and I.V. lines for I.V. fluids and antibiotics)
• Home treatment and outpatient care for moderate and severe acute malnutrition
• Inpatient stabilization care for severe acute malnutrition (SAM) with complications
• First aid for emergency conditions and referral
37
•
•
•
•
•
•
•
•
•
Small surgery (incl. first aid for trauma, stabilization and referral)
Dental care (on fixed days by dental technician, once service is available)
TB diagnosis and treatment (DOTS)
Laboratory examinations
Screening for STIs/HIV and provision of VCT and PMTCT services
Observation, with 10-20 beds
Training (for PHCU staff)
Health Management Information System (clinical documentation, regular reporting, audits)
Administrative and support activities (e.g. register keeping, drug management and maintenance)
5.5. Comprehensive EmONC Primary Health Care Centre (CEPHCC).
BEPHCC are the second level referral centers, where there are county hospitals, the hospital acts as one
such center. They provide all services provided by the BEPHCC and in addition they provide full surgical
obstetrics, with the capabilities of carrying out caesarian sections, other measures for severe uterine
bleeding or damage and safe blood transfusion where necessary. There should be one CEPHCC for every
50,000 women of child bearing age, or a population of 150,000 to 200,000. The HR should include at the
minimum, three health professionals who are “skilled birth attendants,” three competent anesthetists and
three laboratory technicians trained in blood transfusion safety. A comprehensive EmONC PHCC should
have at least two operating theatres to enable sustained safe surgical obstetric interventions. This enables
alternate use of theatres in emergency situations even in the event one of the nits has to be closed because
of contamination or breakdown of equipment.
Comprehensive EmONC PHCC will provide mentorship to PHCU staff and help to create career paths for
the HHP, Village maternal health workers and CHW. They will ensure efficient Health Management
Information Systems for the health services in their catchment areas including administrative and support
activities (e.g. register keeping, drug management and maintenance and, if applicable, book-keeping) and
reporting of all health activities within its coverage.
Summary of key services provided at BEmONCPHCCs
• Preventive care and health promotion
• 24-hour basic Emergency Obstetric and Neonatal Care.
o I.V. antibiotics administered
o I.V. oxytoxics administered
o I.V. anti-convulsants
o Manual removal of the placenta
o Assisted delivery by Vacuum Extraction
o Manual vacuum aspiration of retained products of conception
o Neonatal resuscitation
• Curative care (including I.M. injections and I.V. lines for I.V. fluids and antibiotics)
• Home treatment and outpatient care for moderate and severe acute malnutrition
• Inpatient stabilization care for severe acute malnutrition (SAM) with complications
• First aid for emergency conditions and referral
• Small surgery (incl. first aid for trauma, stabilization and referral)
• Dental care (on fixed days by dental technician, once service is available)
• TB diagnosis and treatment (DOTS)
38
•
•
•
•
•
•
Laboratory examinations
Screening for STIs/HIV and provision of VCT and PMTCT services
Observation, with 10-20 beds
Training (for PHCU staff)
Health Management Information System (clinical documentation, regular reporting, audits)
Administrative and support activities (e.g. register keeping, drug management and maintenance)
5.6. Boma Health Committees (BHCs)
The BHCs will provide administrative support and mentorship. They consist of elected community
members. They should be representative of the whole community and must maintain a gender balance
with women and men equally represented. Among its key functions are:
a. Implementation of community health activities
b. Community participation and involvement
c. Community ownership and development of local leadership
d. Referral system and surveillance
e. Monitoring and Evaluation
f. Monthly work plans by health committees
g. Outreach health programs
h. Health education and promotion
i. Health campaigns and awareness programs
j. Efficient and cost-effective use of resources
5.7. The County Health Department.
The County Medical Officer of Health (CMOH) as the head of the County Health Department (CHD)
guarantees the implementation of the health policy, co-ordinates with other authorities and actors and
oversee health activities by all agencies or stakeholders working , such as, health promotion, curative
services, HMIS, EPI, pharmaceuticals and medical supplies data management for securing commodities,
HR management and administration and finance. The county health department houses the oversight
team. It also Chairs the County Healthy forums that has the responsibility for the development of
comprehensive sector wide county health plan. The CHD guarantees the implementation of the health
policy, co-ordinates with other authorities and actors and supervises specific areas activities that include:
a. Health coordination
b. Assessment and analysis of local health and managerial needs
c. Joint strategic planning based on local needs and problems
d. Contributions towards management of information systems
e. Implementation of health care and services
f. Monitoring and evaluation
g. Referral system and epidemiological surveillance
h. Efficient and cost-effective use of resources
In view of the shortcomings of skilled human resources, many of these functions may be carried out
initially by an implementing partner to whom the BPHS is contracted out or by a separate partner charged
with the responsibility of building the capacity of the CHD, (in case the MoH decides that the possibility
of conflict of interest requires service delivery separating from coordination). It is important that these
functions are located at the CHD and not in the NGO/FBO partner’s office and that continued investment
in infrastructure and capacity building takes place over the years.
39
It is proposed that in the interim, one CHD manage the health services of 2-3 counties. Major decisions
require consensus building between implementing partners and the CHD. Key decisions such as location
of health facilities and appointment of public health staffs have to be approved by the State MoH.
Table 5. Primary Health Care Units (PHCU)
Catchment Population: 15,000 population
Service profile
Human Resources
(Total 8)
Integrated
Essential Obstetric Care:
Technical [5]
Reproductive
Outreach/mobile ANC at the PHCU
-2 CHWs
Health Services
monthly, Normal deliveries, Counseling
for compliance with ANC, referral of
(1 for facility-based
infections to B-EmNOCPHCC,
curative activities, 1 for
Hemorrhages, eclapmsia and severe
community based
sepsis to C-EmNOCPHCC
promotive activities)
Protective Sexual and Reproductive
-2 MCHW (to be
Health (SRH) for women
replaced by Community
Adolescent SRH
Midwife when human
Men’s SRH
resources are available)
Community Based
Integrated Essential Child Health Care
-1 Statistical Clerks
Health Care
(i) EPI: Mobile/Outreach Immunization
of children monthly, support NIDs and
mop up campaigns
Support Staff [3]
ENA: Promotion of BF infant feeding
and weaning practices, GMP,
management of mild to moderate
-2 Dispensers and
malnutrition and referral of severe
Assistant
malnutrition to PHCC
-1 Janitor (1
Community based child survival
guard/cleaner)
Management of local endemic diseases
Control of neglected tropical diseases
Community based prevention, care for
Total staff: [8]
common injuries and rehabilitation
Visual health, Oral Health and Mental
Health
Disease surveillance and emergency
preparedness
Health Promotion
Awareness sensitization and BCC on the
priority health problems
School Health and Nutrition
Community based nutrition and food
security
Community actions for safe environment,
water and sanitation
Routine Health Management Information
M/E and Operations
System, Periodic Surveys and special
Research
studies
Facilities
Equipment
2 Consultation
Rooms
Examination
tables
Delivery room
Delivery table
Dispensing
area / Store
Fetoscope
Waiting area
Latrine
Water store
Stethoscope
Sphygmomanometer
Thermometers
Fetoscopes
Dressing set
Baby scale
Adult scale
Bicycle
40
Table 6. Basic, Emergency Obstetric and Neonatal Care Primary Health Care Centre (BEmONCPHCC)
Catchment population: 25,000
Service profile
Integrated
Reproductive
Health Services
Community Based
Health Care
Health Promotion
M/E and
Operations
Research
Essential Obstetric Care: Daily ANC
treatment for ordinary infections and
SSTI, conduct normal deliveries,
counseling for compliance with ANC,
and for delivery at health facilities.
Referral of APH and severe PPH to
CEmNOCPHCC, and Severe
Hypertensive renal diseases in
Pregnancy and eclapmsia to State
Hospital
Protective Sexual and Reproductive
Health (SRH) for women
Adolescent SRH
Men’s SRH
Integrated Essential Child Health Care
Daily immunization of children
monthly, support NIDs and mop up
campaigns
ENA: Promotion of BF infant feeding
and weaning practices, GMP,
management of mild to moderate
malnutrition and referral of severe
malnutrition with complications to
TFC
Integrated Management of Childhood
Illnesses (IMCI)
Management of local endemic
diseases
Control of neglected tropical diseases
Community based prevention, care for
common injuries and rehabilitation
Visual health, Oral Health and Mental
Health
Disease surveillance and emergency
preparedness
Awareness sensitization and BCC on
the priority health problems
School Health and Nutrition
Community based nutrition and food
security
Community actions for safe
environment, water and sanitation
Routine Health Management
Information System, Periodic Surveys
and special studies
Number of Beds 15
Human
Resources
(Total 21)
Technical
[13]
-2 Medical Assistant/
Clinical Officers
-3 Community
certificated/enrolled
nurses
- 2 Community Midwifes
-2 Nutritionist
-2 Laboratory Assistant
-2 Pharmacy Assistant
Support Staff
[8]
Infrastructure
Equipment
3 Consultation
Rooms
Stethoscopes
Maternity ward
and labor ward
2 general
observation units
Otoscope
Sphygmomanometer
Thermometer
Baby scale
1 Laboratory
Adult scale
Delivery room
Beds, bedding 10
general and
Minor theatre
Dispensing area /
Store
Delivery tables - 3
Fetoscope
-2 Dispensers
Cold chain store
unit
Equipment for basic
EmONC – MVA,
-2 Statistical Clerks
Waiting area
-2 Community Health
Workers
Latrine
Delivery forceps,
vacuum extractor
-2 Janitor (guard/cleaner)
Total Staff: [21]
Protected water
source for
20,000 or more
liters
Staff residential
houses
Electricity
supply 24 hours
or minimum
when required
Surgical toilet tray
set
Manual resuscitation
equipment
Oxygen supply
( portable oxygen
concentrators)
Autoclave /
Sterilizing facility
Cold chain &
Laboratory
equipment
Refrigerator
Bicycles
41
Table 7. Comprehensive Emergency Obstetric and Neonatal Primary Health Care Centre (EmOC PHCC)
Catchment Population: 50,000
Service profile
Integrated
Reproductive
Health Services
Community Based
Health Care
Health Promotion
Essential Obstetric Care (EOC) that
includes Emergency, Obstetric and
neonatal Care (EmONC) ,Post
Abortion Care (PAC), PMTCT,
Post Natal Care (PNC), Family
Planning (FP)
Including Caesarean Section and
Emergency Hysterectomy
Protective SRH for women
Adolescent SRH
Men’s SRH
Integrated Essential Child Health
Care
Management of local endemic
diseases
Control of neglected tropical
diseases
Community based prevention, care
for common injuries and
rehabilitation
Visual health, Oral Health and
Mental Health
Disease
surveillance
and
emergency preparedness
Awareness sensitization and BCC
on the priority health problems
School Health and Nutrition
Community based nutrition and
food security
Community actions for safe
environment, water and sanitation
Number of Beds 25
Human
Resources Facilities
(Total 27)
Technical
[19]
Consultation
Rooms
-3 Clinical Officers
-2 Medical Assistants
-5 Community certificated
Nurse
-2 theatre attendants
-2 Community Midwifes
-2 Nutritionist
-3 field staff (Nurse,
Public Health technician
and Nutrition Assistant)
Support Staff
[8]
-2 Dispensers
-2 Statistical Clerks
-2 Community Health
Workers (Vaccinators)
Counseling
center
Delivery room
Maternity 15
beds
Equipment
Stethoscopes
Otoscope
Sphygmomanometer
Thermometer
Baby scale
Adult scale
General wards
– pediatric 5
beds, Male 5
beds, female,
Children’s 5
Beds, bedding 10
general and
Dispensing
area / Store
Equipment for basic
EmONC
Cold chain
Unit
Minor surgery
equipment
Steralization
Unit
Manual resuscitation
equipment for
neonates
Waiting area
-2Janitor (guard/cleaner)
Latrine
Total Staff: [27]
Water source
for 40,000
liters
Delivery tables - 3
Fetoscope
Surgical theatre for
Caesarian Section,
ruptured ectopic
pregnancy and
emergency
hysterectomy for
raptured utesrus.
Will also serve ot6her
emergency surgeries.
Autoclave /
Sterilizing facility
Cold chain &
Laboratory
equipment
Refrigerator
Communication
equipment
Bicycles
M/E and Operations
Research
Routine Health Management
Information System, Periodic
Surveys and special studies
42
Table 8. COUNTY, PAYAM AND BOMA HEALTH STRUCTURE
Service Profile
Human Resource: 14 Staff + 6 members of Boma Health
Committee
1. County Health Department
Total: 8
-1 County Medical Officer
-1 Disease Surveillance Officer
-1 M&E Officer
-1 County Nursing Officer
-1 Nutrition Officer
-1 Pharmacy Technician/Assistant
-2 Support staff
2. Payam Health Department
Total: 5
-1 Public Health Officer
-1 Health Education and Promotion Officer
-1 Health Supervisor/Medical Assistant
-1 Maternal Health Coordinator
-1 Support Staff
Total: 6
- A committee of minimum 6 people headed by a village elder.
Members should be representative of the different groups e.g.
women, youth, CHW, water and livestock representatives, etc
(Note: The Secretary has to be a CHW)
3. Boma Health Committee
(Plse note that the Boma
Health Committee are not
paid salary)
43
6. MANAGEMENT AND ADMINISTRATIVE ARRANGEMENTS
6.1. Management
It proposes mechanisms for participatory monitoring and evaluation of service provision and creates a
chain of command for proper coordination of decentralized health service delivery system.
The GoSS-MoH health policy has already established a structure for governance that starts from the
National to the community level. The management structures will be integrated with the implementing
partners and technical agencies in hierarchical way to deliver BPHS as illustrated in the organization
diagram below.
For the first three years from 2008 to 2011, the management of BPHS will be contracted out to BPHS
lead agencies who will support the State Ministries of Health (SMoH) and the County Health
Departments (CHDs). The approach is to contract a lead agency that will concurrently build the capacity
of the SMoH and CHDs whilst filling the gap in managerial capabilities. The other is to establish an exit
strategy that will leave behind a grand alliance for “sector wide approach” (SWAP) in health service
delivery. The aim is to establish sound functional strategies that will focus on:
♦ Developing adequate human resource for planning, delivery, monitoring and evaluation of
BPHS from the state through the county, payam and boma levels;
♦ Enhancing health promotion.
♦ Ensuring transparency, accountability, rationality and cost effectiveness in the management
of financial resources for health.
♦ Establishing a monitoring and evaluation system and appropriate information technology to
ensure efficiency in the collection, analysis and archiving to establish and evidence based
health service management systems at all levels.
♦ Elaborating short and medium term plans and that collectively contribute to the long term
strategy.
♦ Harnessing the comparative strengths of NGOs in the management of integrated activities
that focus on short or medium term goals, and interactive partnerships with beneficiaries in
the management of social and development services to enhance performance.
Because of the capacity building nature of BPHS, the management structures will adopt a mentorship and
guidance approach to oversight of functions and workers at PHCC, PHCU and village levels. This will
entail constant feedback to the lower level of the system to improve overall performance of the system.
Material and technical support will be provided to health service providers. Communication needs to be
both ways, and the management structures will need to enable PHCC, PHCU and Boma levels to feed
back to enable advocacy for the health service needs of the people at the respective levels.
These management structures will also work as the health service management teams for the respective
levels. They will be responsible for the planning, oversight of implementation, monitor and internal
evaluation. They will be responsible for preparation of results based annual work plans for their
geographical areas of work. These will be collated into annual county health plans to be forwarded to the
state. The preparation should be timely in readiness for incorporation into the state and MoH budgets. The
plans will be expected to be developed following feedback, assessments and after reviewing the available
health information.
44
6.2. Logistics Establish functioning logistics system for efficient delivery of BPHS.
BPHS needs commodity inputs including vaccines, medicines, equipments, tools, vehicles and other
supplies. These inputs have to be appropriately selected, quantified, and reach the health facilities in time.
Any delay or shortage may cause a problem on the program or service and result in the dissatisfaction of
the community and loss of confidence and frustration of the health workers at each level. For this to
materialize there needs to be a well functioning MoH logistics system as well as the resource
requirements carefully calculated and budgeted for on an annual basis.
6.3. Extending the national health management information system (HMIS)
Collection and interpretation of health service data is an essential component of BPHS. It enhances health
service management through evidence based decision making. It is critical that information from the
village/PHCU/PHCC level is collected and collated at the various levels to feed into the national Health
Management Information System (HMIS). This includes the contribution of the community level
activities to provide opportunity for evidence based planning of health services. Such information are first
used locally (in discussion with Boma and village leaders), and then transmitted up through weekly and
monthly morbidity/mortality reports via the PHCC to the County, State and the National HMIS.
Operational constraints to implementation, enabling factors, and key lessons learned are identified,
recorded and discussed to find local solutions or transmitted upwards for guidance. The results are
discussed at regular coordination meetings to tease out best practices that can be shared between the
network of service and technical agencies to improve overall local and national performance and for
international comparison.
45
The Government of Southern Sudan
Ministry of Health
Directorate of Preventive Health Services
List of priority Communicable diseases
GROUP A DISEASES:
Immediate/Weekly Reporting:
1. Cholera
2. Diarrhea with Blood ( Shigellosis)
3. Measles
4. Meningitis
5. Viral HemorrhagicFever
6. Yellowfever
7. RelapsingFever
8. AcuteJaundice Syndrome
9. AcuteFlaccid paralysis
(AFP)/Poliomyelitis
10. Neonatal tetanus
11. Acute watery Diarrhea
GROUP B DISEASES:
Monthly Reporting:
12. Plague
13. Dracunculiasis*
14. Lymphatic filariasis
15. Tuberculosis
16. Leprosy
17. HIV/AIDS
18. STIs
19. Malaria
20. Pneumonia
21. Schistosomiasis
22. Rabies
23. Trypanosomiasis
24. Kala-Azar
25. Onchocerciasis
* should be reported immediately when detected for the first time from an
area which is not known to be endemic or which was formerly endemic
and had interrupted indigenous transmission
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Standard case Definitions for Priority
Communicable diseases in Southern Sudan
Cholera
Any person 5 years of age or more who develops severe dehydration or
dies from acute watery diarrhea
Diarrhea with Blood
(Shigellosis))
Any person with acute diarrhea and visible blood in the stool.
Measles
Any person with fever and maculo-papular (non-vesicular) generalized
rash and cough, coryza or conjunctivitis (red eyes) or any person
in whom a clinician suspects measles.
Meningitis
Any person with sudden onset of fever (>38.0 0C) and one of the
following signs: neck stiffness, altered consciousness or other
meningeal signs. Suspect meningitis in a patient less than one
year of age: fever with bulging fontanel.
Plague
Any person with sudden onset of fever, chills, headache, severe
malaise, prostration, and very painful swelling of lymph nodes, or
cough with blood-stained sputum, chest pain, and difficulty in
breathing.
Viral hemorrhagic
fevers
Any person with severe illness, fever, and at least one of the following
signs: bloody stools, vomiting blood, or unexplained bleeding from
gums, nose, vagina, skin or eyes.
Yellow fever
Any person with sudden onset of high fever (>38.0 0C), followed by
jaundice within two weeks of onset of first symptoms.
Relapsing fever
Any person with febrile illness with alternative afebrile period in
between; with or without headache, petechial skin and mucous
membrane rashes.
Acute Jaundice
Syndrome
Acute onset of jaundice and severe illness and absence of any known
precipitating factors
Acute flaccid paralysis
(AFP)/poliomyeliti Any single case of weakness or paralysis that is floppy and of sudden
s
onset, not due to injury, in a child less than 15 years of age OR
any case of any age if a clinician suspects polio.
Drancunculiasis
Any individual exhibiting a skin lesion with emergence of a worm
Acute Watery Diarrhea
Three or more abnormally loose stools in the past 24 hours with or
without dehydration.
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Standard case Definitions for Priority
Communicable diseases in Southern Sudan
Pneumonia in children
Pneumonia
less than 5 years of
Any child aged 2 months up to 5 years of age with cough or difficult
age
breathing and
– breathing 50 breaths or more per minute in an infant 2 months up to #1
year
– breathing 40 breaths or more per minute for a child aged 1 to 5 years
(Infants less than 2 months with fast breathing 60 breaths or more per
minute are referred for serious bacterial infection.)
Severe Pneumonia
HIV/AIDS
Any child age 2 months up to 5 years with cough or difficult breathing, and
with any general danger sign, or chest in drawing, or stridor in a calm
child. General danger signs are: unable to drink or breast-feed, vomits
everything, convulsions, lethargy or unconsciousness.
Any person who meets the AIDS case definition adopted by national policy.
Malaria
Any person presenting with fever with chills, shivering, sweats, headache,
joint pain, nausea and vomiting.
Onchocerciasis
In an endemic area, any person with fibrous nodules in subcutaneous
tissues, intense itching and skin changes.
Sexually transmitted
infections (STIs)
Genital ulcer syndrome (non-vesicular)
Any male with an ulcer on the penis, scrotum, or rectum, with or without
inguinal adenopathy, or any female with ulcer on labia, vagina, or
rectum, with or without inguinal adenopathy.
Urethral discharge syndrome
any male with urethral discharge with or without dysuria
Trypanosomiasis
Early stage trypanosomiasis
Any person with a painful chancre that originates as a papule and then
evolves into a nodule at the fly bite site. There may be fever, intense
headache, insomnia, painless lymphadenopathy, anaemia, local
edema and rash.
Late stage trypanosomiasis
Cachexia, somnolence, and central nervous system signs
Pulmonary Tuberculosis
Any person with cough for 3 weeks or more
Kala-Azar
A person with clinical sign of prolonged irregular fever ( more than 2 weeks),
splenomegaly and weight loss
Lymphatic filariasis
A person with hydrocele, elephantiasis of the limbs, breast and the genitalia,
Schistosomiasis
S. mansoni , diarrhea, abdominal pain and hepato-splenomegaly
S. hematobium , dysuria, terminal hematuria and urinary frequency,
Rabies
A person with a history of dog or any suspected animal bite and presenting
with irritability, hydrophobia and hyper-salivation
48
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