South Sudan
DRAFT SOUTH SUDAN HEALTH SECTOR RISK
ANALYSIS
SEPTEMBER 2016 – December 2017
Table of Content
Contents
Table of Content .......................................................................................................................................................................................... i
List of Figures ............................................................................................................................................................................................. ii
List of Tables .............................................................................................................................................................................................. ii
List of Abbreviations .................................................................................................................................................................................. iii
Acknowledgement ..................................................................................................................................................................................... iv
Executive Summary .................................................................................................................................................................................... v
1.0 Introduction ..........................................................................................................................................................................................1
1.1 Rationale of the Assessment ................................................................................................................................................................1
1.2 Objective...............................................................................................................................................................................................2
2.0 Country Profile/Humanitarian Situation ...............................................................................................................................................3
2.1 Challenges of the Current Context ...................................................................................................................................................3
2.1.1 Unstable political environment: ...................................................................................................................................................3
2.1.2 Economic crisis..............................................................................................................................................................................3
2.1.3 Inaccessibility ................................................................................................................................................................................3
2.1.4 Poor Access to Education, Water and Sanitation Services ............................................................................................................3
2.1.5 Displaced Persons and Refugees ..................................................................................................................................................4
2.1.6. Food insecurity ............................................................................................................................................................................4
2.1.7. Limited presence of Implementing/Health cluster Partners........................................................................................................4
2.1.8. Poor Access to Health Services ....................................................................................................................................................4
2.1.9. Poor Health Systems Outcomes: .................................................................................................................................................5
3.0 Methods ...............................................................................................................................................................................................6
3.1 Design of the Assessment ................................................................................................................................................................6
3.2 Operational Definition of Variables .................................................................................................................................................6
3.3 Limitations: ......................................................................................................................................................................................7
4.0 Results and Discussion ..........................................................................................................................................................................8
4.1 Health hazard Profile .......................................................................................................................................................................8
4.2 Vulnerability Analysis .....................................................................................................................................................................11
4.3 Capacity to Respond (Health System) ............................................................................................................................................14
Figure 10: Total Weighted Score for Capacity to Respond (Health System) .............................................................................................16
4.4 Composite Public Health Risk ........................................................................................................................................................17
Figure 11: Total Composite Weighted Risk ...............................................................................................................................................17
5.0 Conclusion and Recommendation ......................................................................................................................................................18
References: ...............................................................................................................................................................................................21
i
List of Figures
Figure 1: Multiple Outbreaks of Communicable Diseases ................................................................................... 8
Figure 2: Total Weighted Socre for Hazard ........................................................................................................ 10
Figure 3: Access to Safe Drinking Water and Latrines ........................................................................................ 11
Figure 4: Urban/Rural Population Distribution per State ................................................................................... 11
Figure 5: Use of health facilities for Child Fevers ............................................................................................... 12
Figure 6: Literacy Rate per State ........................................................................................................................ 12
Figure 7: Total Weighted Score for Vulnerability ............................................................................................... 13
Figure 8: Trend of Partners' Presence before, during and immediately after the July 2016 crisis .................... 14
Figure 9: Immunisation Coverage, 2016............................................................................................................. 15
Figure 10: Total Weighted Score for Capacity to Respond (Health System) ...................................................... 16
Figure 11: Total Composite Weighted Risk ........................................................................................................ 17
List of Tables
Table 1: Weighted Scale of Risk............................................................................................................................ 7
Table 2: Coverage of ANC 4+ visit and Supervised Delivery, 2016 ..................................................................... 15
ii
List of Abbreviations
ANC
ART
CFR
DFID
EPR
ERW
EWARS
GDP
HIV
IDP
IHR
IMCI
LB
MoH
NGOs
OCHA
PHCC
PHCU
PLHIV
PoCs
TB
TGoNU
UN
Unicef
UNMAS
USAID
WB
WHO
Antenatal Care
Antiretroviral Therapy
Case Fatality Rate
Department for International Development
Emergency Preparedness and Response
Explosive Remnants of War
Early Warning Alert and Response System
Gross Domestic Product
Human Immunodeficiency Virus
Internally Displaced Persons
Internal Health Regulations
Integrated Management of Childhood Illnesses
Live births
Ministry of Health
Non-Governmental Organisations
Office for the Coordination of Humanitarian Affairs
Primary Health Care Centres
Primary Health Care Unit
People Living with HIV
Protection of Civilian sites
Tuberculosis
Transitional Government of National Unity
United Nations
United Nations Children’s Fund
United Nations Mines Action
United States Agency of International Development
The World Bank
The World Health Organisation
iii
Acknowledgement
The WCO South Sudan wishes to express appreciation to the Team of Staff evacuated to Nairobi,
who upon the urgent request of the Office produced this document in the course of responding to the
July 2016 crisis in South Sudan. The WCO is especially grateful to the Team leader for this
document, Dr. James. K. Teprey as well as Kofi Boateng (Consultant) and Mr. Gai Malick
(Information Management Officer) for their input in the development of the content of the document.
Further gratitude is extended to all colleagues both in Juba and Nairobi for providing vital
information and clarification that enabled the production of this document.
The technical and logistical support from the WR is also very much appreciated.
iv
Executive Summary
Prior and post-independence, the Republic South Sudan has been in protracted state of recurring
crisis. Ministry of Health, Health partners and donors have made significant contributions over time
to build the health sector, albeit weakened in recent times due to the effects of the crisis. As a result,
health services delivery has been severely challenged exposing the entire population to multiple
infectious diseases outbreaks including cholera, measles and cholera, and also posing health security
questions.
The low socio-economic status coupled with the chronic crisis has left over 5.1million persons in
need of humanitarian assistance.
The objective of this risk assessment is to identify, evaluate the common hazards, estimate the
probability of occurrence and recommend risk management measures to reduce the potential impact
of the potential disasters, disease outbreaks and emergencies
The WHO South Sudan as the lead agency for health embarked on an appraisal of the public health
risk assessment of the situation in South Sudan using a three step analysis on hazards, vulnerability
and capacity to respond (health systems) based on Ministry of Health data sources over the last
2years. Weighted scores of all elements of the three indicators were determined by a team of WHO
experts. A weighted-composite score was determined and results mainly presented in maps and
graphs depicting disparities of elements of the three variables as well in the former 10 states. Due to
limited data the team could not consider analysis for the newly created 28 states and also previous
and newly created counties; however the assumption is that based on the risk maps, decision makers
can be well guided by the risk to newly created areas.
The entire country is highly burdened with multiple hazards, vulnerabilities and with very weak
capacity to respond in all the 10 states. Hazards including multiple infectious diseases outbreaks,
floods, explosive remnants of war and communal conflicts are very high in Jonglei and high in Unity
Warrap and Lakes states. In terms of vulnerability informed by rural/urban population, female
education and health seeking behavior, Unity and Jonglei are highly vulnerable. None of the 10 states
has the capacity alone to respond to public health emergencies. However, the weighted-composite
risk showed that all states in South Sudan are at varying risks with Unity state at very high public
health risk, Jonglei and Northern Bahr El Ghazal at high risk, Upper Nile, Lakes, Warrap, Western
Bahr El Ghazal, Western Equatoria and Eastern Equatoria at moderate risk, and Central Equatoria at
mild risk. The presence of other security threats like Explosive Remnant of War Jonglei and Upper
Nile is likely to compound response actions in case of a disaster or a major disease outbreak.
Special attention should be given to improving health information systems integrated with highly
sensitive surveillance system, human resource management and development, coordination, and
limiting vertical programming to avoid missed opportunities and enhancing joint ownership and
monitoring through strengthening community health components of the health services. In states that
are most vulnerable, priority should be given to enhanced health prevention and promotion
interventions. The role of Anthropologist and Health Psychologist would be crucial in managing
highly infectious diseases such as a pandemic. Early warning systems should be established and
strengthened in states with very low capacity to respond for timely actions. Mobile hospitals or
clinics would be required when there are disasters and diseases outbreaks.
It is therefore recommended that a multi-partner platform is created to pull both humanitarian and
development efforts in terms of integrated coordination, design, implementation, and monitoring high
impact state specific health interventions that are sustainable and aimed at building a community
based
resilience
for
accelerated
health
outcomes.
v
1.0 Introduction
Risk analysis is the evaluation of the probability of occurrence and the magnitude of the
consequences of any given hazard, (how likely is a hazard and what consequences will it have) and
the probability of a disaster occurring. The evaluation of a risk includes vulnerability assessment and
impact prediction taking into account thresholds that define acceptable risk for a given society. All
hazard approach determines vulnerability and the capacity of the health sector to respond to any
hazard according to revised IHR 2007. This therefore tries to analyze the public health risk of
multiple hazards in South Sudan.
The July 7 2016 conflict in South Sudan was among the several recurring crisis that have bereft the
country before and after independence. The recurring crises have had several dimensional effects on
social services including health. The Ministry of Health and partners both developmental and
humanitarian have jointly made several efforts in improving the health and health related indicators.
However, despite years of interventions, gains are easily waned due to multiplicity of factors
including the arm conflict. The Health partners and agencies continue to raise questions about the
health strategies that can best inform the design of interventions of high impact to avert preventable
morbidity and mortality, as well as to mitigate the public health risk of the deteriorated situation in
the population. Guidance from event specific assessment conducted by clusters and partners and
also, regular epidemiological updates on priority disease have not adequately provided a
comprehensive outlook of the public health risk of events within the context of the complex
emergency in South Sudan
WHO Country Office of South Sudan, as the lead agency of health, used the opportunity of activation
of its three-level emergency mechanism, to conduct the public health risk assessment of the crisis in
South Sudan from July – September 2016. The aim is to inform partners and respond to specific
needs enlisted in the section below.
1.1 Rationale of the Assessment
This assessment was informed by the following needs:
1. Due to the protracted crisis in South Sudan, there is limited evidence to guide prioritization of
programmes and partners intervention for high impact.
2. In face of threat of new and emerging public health emergencies, evidence of South Sudan’s
capacity to cope with the current threats and risk will guide and inform policy decisions for
building a resilient health system.
3. Advocacy to Government and other partners to address critical health issues should be guided
by evidence for which this assessment intend to provide
4. WHO as the lead agency for health need adequate tools to inform, guide and advice partners
on priority areas and advocate for resource mobilization.
1
1.2 Objective
The objective of this risk assessment is to identify, evaluate the common hazards, estimate the
probability of occurrence and recommend risk management measures to reduce the potential impact
of the potential disasters, disease outbreaks and emergencies.
Specific objectives:


Identify the common hazards, vulnerability of the states and their capacity to respond
Recommend high marginal output interventions for the most at risk states in South Sudan
2
2.0 Country Profile/Humanitarian Situation
The Republic of South Sudan has a population of 12.3 million and covers a geographical surface area
of 645,000 sqkm(1,2). The country gained its independence on 9th July 2011 and has experienced
bouts of internal conflicts ever since; especially after December 2013. The Peace Agreement signed
in Addis Ababa on 27th August 2015 provided for the formation of the Transitional Government of
National Unity (TGoNU) however the conflict erupted again on 7th July 2016. The resurgence of
conflict, insecurity and instability has reflected negatively on the political, social and economic status
of the country, with severe consequences for the population3; and has resulted in the sharp increase in
both humanitarian and developmental needs. To date, an estimated 5.1 million people need
humanitarian assistance in South Sudan4,5.
2.1 Challenges of the Current Context
2.1.1 Unstable political environment:
Progress in the implementation of the 30-month road map sanctioned the Peace Agreement has been
slow. The adherence to key elements, including cessation of hostilities, has been a major concern.
The divisions among the political echelon coupled with the tribal dimension and the unresolved
tensions around the creation of the 28 States in 2015 have led to very deep divisions among social
and political leadership with most severe implications on the population and further heighten
humanitarian needs3.
2.1.2 Economic crisis
The Republic of South Sudan is oil dependent; with oil revenues accounting for 60 percent of Gross
Domestic Product (GDP). The global downturn of oil prices resulted in the country’s revenue
inflows drastically dropping and in turn determining lower national allocations to social sectors of the
economy including health where the Government’s allocation had dropped from 7 percent in 2012 to
less than four (4) percent in 2015. Inflation is also very high and increasing, with the South Sudanese
Pounds (SSP) depreciating drastically – e.g. between January to July 2016, the SSP rate to a dollar
devaluated from 32.1 to 60 in the open market5,6.
2.1.3 Inaccessibility
South Sudan has less than 10 percent of access roads to major states capitals and therefore 70 percent
of logistics operations are by air. The topography of the country makes its highly prone to floods in
the rainy season which lasts from April – October each year leaving only 5 months of ground access
for effective implementation of activities. Due to these challenges coupled with the poor economic
condition, logistics management is not only difficult but also one of the most expensive in the
region6,7.
2.1.4 Poor Access to Education, Water and Sanitation Services
Primary School intake is only 11.2% and the literacy rate among young women is 13.4% contributing
to unhealthy behavioral tendencies within households and challenges with the assimilation of health
3
promotion concepts. There is no national water distribution system, and only 55% and 7% of
households were estimated to have access to safe drinking water and pit latrines, respectively. The
environmental risk factors for water-borne and water-related diseases including Cholera, Typhoid,
Hepatitis E, and Guinea Worm, is very high (8,9).
2.1.5 Displaced Persons and Refugees
Since the conflict began in December 2013, it is estimated that 1 in 5 people in South Sudan has been
displaced. More than 2.3 million citizens have been forced to flee their homes, including over
720,000 people who fled to Uganda, Ethiopia, Kenya, Congo DRC and Sudan; and an estimated 1.6
million displaced within the country. The recent conflict on 7 July 2016 has resulted in 538 injured,
382 fatalities and 35,094 additional displaced persons in five (5) IDP camps including 2 Protection of
Civilian Sites (PoCs) within the United Nations (UN) compound in the capital Juba. In July 2016, the
UN Mission in South Sudan estimated that over 200,000 persons are known to be residing in PoCs.
In addition, some 266,916 refugees from Sudan are hosted in South Sudan. In spite of the on-going
efforts, the majority of IDPs, including those in the UN compounds, are living without adequate
shelter, in overcrowded and poor sanitary environments conducive for disease outbreaks, and yet
without adequate life-saving health services (4,5).
2.1.6. Food insecurity
An estimated 4.6 million population in South Sudan is at risk of hunger; consequently, the risk of
malnutrition among under-five children is high. Currently severe acute malnutrition rate is 9.8
percent among under-five children; 20 percent of which are estimated to require in-patient treatments
at the health facilities due to medical complications (5).
2.1.7. Limited presence of Implementing/Health cluster Partners
The health situation had already been fragile before the onset of the current conflict. Out of the 67
health partners present prior to the crisis flare up, about 19 have skeletal representation in the country
(10)
.
2.1.8. Poor Access to Health Services
The majority of the population does not have access to regular basic primary health services. This is
the compounding result of low population density (i.e. 15 persons per square kilometers), the largely
rural and highly dispersed settlements (80 percent of the population)(11), and also the limited and
decreasing number of functional health facilities due to the protracted state of insecurity and conflict
in the country. Prior to 7th July 2016, only about 56 percent of the population had access to
functional health facilities, which were mostly (80 percent) managed by NGOs (11,12). The
exacerbation of the conflict since July 2016 has further crippled the delivery of health services in the
country. Looting and destruction of health facilities, displacement or relocation of health workers,
mass evacuation of partners and fund managers, all contributed to further reduce the number of
functional health, while the remaining ones provide extremely minimal range of services (4,10). All
these have negatively impacted on delivery primary health services packages including basic
consultations, vaccinations, emergency obstetric services, nutrition, management sexual and genderbased violence.
4
2.1.9. Poor Health Systems Outcomes:
South Sudan has some of the worst health indicators globally which implies a high risk of mortality
and morbidity both in the general population and among vulnerable groups including women and
children. Maternal mortality ratio is estimated at 798/100000 live births (LB) 70/100,000; neonatal
mortality rate at 39/1000LB 12/100; infant mortality rate is 84/1000; while under-five mortality rate
is 105/1000LB (25/1000)(13,14). Over 60 percent of under-five years, mortality is attributed to
neonatal deaths. These indicators reflect the relatively poor health status of the general population,
and further, demonstrate the deep gaps that need to be addressed to ensure equitable access to basic
lifesaving interventions (15).
The country has an acute shortage of health workers; far below the global critical levels of 4.4/1000
population. Doctors to population ratio stand at 0.015 per 1000, while midwives/nurses population
ratio is 0.02 per 1000. A recent review of the human resources profile showed that only 3 out of 119
PHCCs had the minimum technical staff employed according to MOH standards, and only 13 percent
had one of each required cadre(16,17).
At the height of the crises, the majority of government health staff members deserted and fled their
duty stations due to multiple reasons including insecurity, non-payment of salaries, and absence of
employers (NGOs). The quality of health service delivery has deteriorated affecting all populations in
South Sudan. In the 2013 Health Facility Assessment Survey of 119 facilities conducted in accessible
areas, only nine (9) percent had the minimum required an infrastructure (which included a working
ambulance) and six (6) percent had all essential equipment needed to perform IMCI consultations,
although 67 percent had a working vaccine refrigerator. Infection control was compromised, with
only eight (8) percent of PHCCs passing for this indicator. Less than 30 percent had some means to
properly sterilize instruments, and only 64 percent had soap for hand washing (16).
Health Information Management capacity exists albeit weak due to the limited presence of
implementing partners. IDSR strategy focusing on capturing 14 priority diseases was implemented
country wide in 1392 health facilities, however currently only 37% of the facility are reporting. To
ensure timely reporting for displaced populations, the EWARS is implemented in 2 of10 states
focusing on the conflict-affected states of Unity and Upper Nile as well as Protection of Civilian sites
(PoCs) in Bentiu, Malakal, and Bor. The EWARS which targets 48 reporting sites is currently
reporting at a 52 percent rate. Data sources from other critical interventions including maternal and
child health are limited (18).
Procurement and distribution of Essential Medicines and Supplies are supported by donors through
several fragmented initiatives funded mainly by USAID, DFID, WB and Norway. There have been
regular shortages of critical medicines in the majority of the health facilities. In terms of emergency
kits, WHO had adequately preposition supplies with additional planned pipelines to respond to the
unpredicted nature of the current situation (17).
There has been a critical shortage of blood and blood products with donations at about 40,000 units
per year which are less than 25 percent of the national need (19). This exacerbates deaths due to
maternal bleeding, anemia in children, severe malaria, war-related trauma and injuries, and road
traffic accidents, surgical cases and other medical conditions requiring a blood transfusion.
5
3.0 Methods
3.1 Design of the Assessment
Risk analysis can be qualitative or quantitative. This analysis was based on a desk review of existing
data from MOH, WHO, and other several sources as well as consolidation of WHO experts’ guided
experience of programming in South Sudan. We applied the concept of Risk determination based on
multiple hazards, their impact and vulnerability using the formula - Risk = Hazard x Vulnerability /
Capacity x k (where k is the attack rate and or case fatality rate of the Hazard Agent). Thus the risk of
occurrence of any outbreak or disaster will vary according to the type of agent, severity and
infectiousness of the hazard. Generally the vulnerability and capacity of the health sector to cope may
not change very much at the time.
The evaluation of the risks was done on a graded numerical scale agreed by the team on the
description and perception of the hazards, vulnerability and capacity to respond. This was followed
by quantitative composite public health risk calculation and analysis to determine the probabilities
over the possible consequences per state. The results were regrouped into a five continuum scale of
risk categorized into: “low”, “mild”, “moderate”, “high” and “very high”. We further conducted a
combined analysis of hazards, vulnerability, and capacity to respond to obtain a composite risk
estimate which was summarized d in a graphical presentation.
3.2 Operational Definition of Variables
We conducted three-step analyses of the key determinants of risk stratified per state as follows
3.2.1 Hazard Analysis:
We selected epidemic-prone diseases delimited by available data. These were malaria, measles,
polio, cholera, meningitis and viral hemorrhagic fevers. Also, exposure to floods, unexploded
ordinance, food insecurity, communal conflict, displacement and rural-urban migration were
included.
3.2.2 Vulnerability Analysis:
We analyzed vulnerability based on social determinants and health seeking behavior. Social
determinants were assessed on urban and rural population distribution, literacy levels of women,
access to safe water, latrines and poverty levels. We also used caretakers’ health seeking behavior to
childhood fevers focusing on the choice of services as a proxy for assessing the risk of vulnerability.
3.2.3 Capacity to Respond (Health Systems):
We analyzed service delivery, public health capacity, capacity for early warning and financing.
Indicators for service delivery were limited to a percentage of supervised delivery, ANC +4 visits,
and penta3 coverage while Measles and Polio3 coverage were applied for public health capacity.
Reporting rate, completeness, and timeliness were indicators used for early warning. Government
budgetary allocation to health was used as a proxy for health financing per state.
3.2.4 Composite Public Health Risk
The composite Public Health Risk is a combined weighted score of hazards, vulnerability and
capacity to respond which is also graded at five-levels as shown in Table 1 below. The public health
risk was defined as the likelihood of exposure to hazards, vulnerability and capacity to respond on
6
the geographic area and the population should a disaster or disease outbreak occur. Thus, the higher
the public health risk, the likelihood that key health sector actions to mitigate consequences are
required but at the same time could be very challenging due to the multiple hazards, extent of
vulnerability and multiple intervention for capacity building.
3.2.5 Weighted Scale of Risk
Table 1: Weighted Scale of Risk
Variables
Hazards
Vulnerability
Capacity to Respond
Composite Public Health Risk
Total
weighted
Score
30
16
12
58
Ranking of Risk of Weighted Scores
Moderate
High
Low
Mild
<5
<3.2
<2.4
<11.6
5-10
3.2 -6.4
2.4-4.8
11.6 – 23.2
10 - 15
6.4-9.7
4.8 -7.2
23.2 – 34.8
15-20
9.7 -13.0
7.2 – 9.4
34.8 – 46.4
Very high
>20
>13.0
>9.4
>46.4
3.3 Limitations:
Several key variables were identified but the team could not access these at the time. Either they were
not available or required further consultation with the MoH in South Sudan for which more time was
required. Thus proxy indicators and variables were used to assess the risk. Analysis on second
administrative levels (counties) could not be done due to limited data, thus the analysis was restricted
to risk levels per state. Some of the consensuses may also be biased based on the team’s perception
of the risk elements. The effect of the conflict and insecurity was not considered in the analysis
because the available data was scanty. Due to the low reporting rates from counties estimates may
likely to have been biased in the determination of the magnitude of the diseases (communicable
diseases) and service coverage, however, we assumed that the proxy of different counties could
provide fair representation for the state. Our approach of determining composite public health risk is
informed by the limitation of guidelines for multiple hazard and vulnerability assessments. We were
therefore unable to quantify the magnitude of the composite public health risk; however we assumed
that having identified the areas at risk the inhabitants will face multiple consequences.
7
4.0 Results and Discussion
4.1 Health hazard Profile
South Sudan has been experiencing different disasters ranging from natural to man made over the last
years. In the health sector, communicable diseases were highly endemic and persistent outbreaks of
measles, malaria, hepatitis E, Kal Azar and injuries were major public health concerns. Following the
conflict and the resultant displacements of thousands of persons, conditions for exposure to health
and health related hazards became suitable. This included outbreaks of diseases, sexual and genderbased violence and trauma.. The level of risk of occurrence of any outbreak or disaster will vary
according to exposure to the type of agent and hazard and may require a rapid hazard specific
analysis of the sector.
4.1.1Cholera:
Cholera outbreaks occurred in 2014
and 2015 recording a total of 8,208
cases and 186 deaths with CFR
ranging 1.95 among the IDPs to 5.86
in the general population. By mid of
July 2016, there was cholera outbreak
in Juba and Terekeka in Central
Equatoria, Duk, in Jonglei and
Nimule in Eastern Equatoria and
Minkanman in Lakes. As at 2nd
August 2016, there were 2119 cases
and 31deaths reported with case
fatality rate of 1.5percent. Current
case fatality resulting from the
ongoing cholera outbreak ranges from
0.6 percent in Juba to 12.8 percent
and 40 percent Terekeka counties
respectively (20).
4.1.2 Malaria
Figure 1: Multiple Outbreaks of Communicable Diseases
Malaria upsurges have also been recorded in three States in Lakes, Northern Bahr El Ghazal and in
one PoC, Bentiu, in Unity State. During the period January – July 2016, 828,523 malaria cases have
been reported accounting for 58 percent of all morbidity and 30 percent of all mortality. Children
under five years are at high risk of death from malaria. Even though control measures had
commenced, it is challenged by the withdrawal of partner’s presence(18, 22).
4.1.3 Measles:
Measles is endemic in South Sudan with persistent outbreaks (average 22 per year) due to the very
low population immunity (42.5 percent), resulting from the weak routine immunization coverage (25
percent) coupled with the effects of population displacement by the crisis. In 2016, 648,000 children
under the age of five years are estimated to be at risk of measles. Over the period Jan – July 2016, 25
outbreaks with over 200 cases were reported in 5 of 10 states in the country. The annual routine
immunization coverages for measles are only 25 percent. This has left over 390,000 children
8
unimmunized as of July 2016, when the recrudescence of violence and insecurity occurred,
disrupting preparations for the planned follow-up campaign in October (23, 24).
4.1.4 Kal Azar:
The year 2016 is predicted for outbreaks of Kal Azar based on 5-7 year trends of outbreaks since
1990. States at high risk include Jonglei, Unity and Upper Nile that are known to be endemic to the
diseases. Case Fatality Rates estimated from previous outbreaks has ranged from five (5) percent - 50
percent in these places currently inhabited by an estimated 3.1million (25).
4.1.5 HIV (PLHIV), TB and Hepatitis:
More than 190,000 People are Living with HIV (PLHIV); including 23,000 on antiretroviral therapy
(ART). Total 13,000 people are newly infected with TB each year; with only about 60 percent put on
anti-TB therapy. Total 12 percent and eight (8) percent of adults are chronically infected with
Hepatitis B and C respectively. The risk of spread and death due to these diseases in the general
population will be very high due to limited access to services (27).
4.1.6 Sexual and Gender Based Violence:
The incidence of sexual and gender-based violence has dramatically increased during and since the
recent resurgence of violence, with over 120 cases of rape has been reported since July 7, 2016 (4, 10).
4.1.7 Mental and Psychosocial conditions:
The protracted conflict in South Sudan has resulted in the high burden of mental and psychosocial
conditions that have not been properly documented and addressed. Thousands of households both
displaced and not displaced have experienced traumatic events, with Post Traumatic Stress Disorder
estimated at 36 percent. Besides, the burden of other Non-Communicable diseases is high. It is
estimated that 19 percent and 8.3 percent of the population have hypertension and diabetes mellitus
respectively(27).
4.1.8 Floods:
All states except Western Equatoria are flood prone with annual occurrence recorded during the rainy
season. The highly prone states are Jonglei, Upper Nile, Unity, Warrap and Northern Bahr El Ghazal.
During floods, there are displaced populations to higher lands within the states (4,5).
4.1.9 Explosive Remnants of War (ERW):
There continue to be residual unexploded
ordinances in all states following decades of
war with Sudan. However, the internal crisis
has resulted in increased planting of landmines
in Unity, Upper Nile and Jonglei considered
high risk. All others state have moderate
exposures (28). The singular threats of mines can
exacerbate the vulnerabilities, capacity and
9
response to any disaster and disease outbreak in those states.
4.1.10 Communal Conflict:
Communal conflict resulting from revenge attacks and cattle raiding is persistent in South Sudan. It is
predominant in Lakes and Warrap and the equatoria regions comprising Western, Central and Eastern
have been recently exposed mainly due to the raiding of farm lands by herdsmen migrating from the
Bahr Ghazal states of Northern and Western Bahr El Ghazal, as well as Lakes and Warrap (5).
4.1.11 Total Weighted Score for Hazard
Figure 2: Total Weighted Score for Hazard
Examining the effects of outbreaks of communicable diseases in the last 2years, the number of
people affected and the case fatality rates coupled with known exposures to floods, unexploded
ordinances, and communal conflicts, Jonglei state recorded the highest number of weighted hazards
in South Sudan. Western, Lakes, Warrap and Unity had moderately weighted hazards while the rest
including Central Equatoria had mild weighted hazards.
10
4.2 Vulnerability Analysis
Access to Safe Drinking Water and Latrine
4.2.1 Safe drinking water and sanitation
Access to safe drinking water ranges from
state to state. For safe drinking water, only
one state Central equatorial (58%) has
coverage of more than 50%. All others are
below 50% with Unity having the lowest
coverage of 7%. Latrine coverage for all the
states is below 15%. Only Western Equatoria
has 12 and the lowest, Warrap, has the lowest
of one percent latrine coverage. Diseases
caused by poor hygiene, poor water quality
and poor sanitation coverage such as cholera,
acute watery diarrhea, acute bloody diarrhea
and hepatitis E outbreaks pose a serious threat
to the whole country especially Warrap,
Northern Bahr El Ghazal, Unity Lakes and
Jonglei states and areas hosting large
internally displaced persons(11).
Western Equatoria
Western Bahr El Ghazal
Warrap
Upper Nile
Unity
Northern Bahr El Ghazal
Lakes
Jonglei
Eastern Equatoria
Central Equatoria
0
10
20
30
40
50
60
70
Percentage
Figure 3: Access to Safe Drinking Water and Latrines
Percentage Access to Laterine
Percentage Access to Safe Water
4.2.2 Rural-Urban and urbanization
Urban/Rural Population Distribution
by State
Population Percentage
Eighty two percent of the total population of
South Sudan lives in rural settings. The urban
areas also harbor a large number of displaced
persons. Western Bahr El Ghazal has the
urbanest population of 43% followed by Central
Equatorial 35%. Western Bahr El Ghazal is not
very much affected by the conflict and is one of
the most stable states. Central Equatorial hosts
the capital city of South Sudan and at the same
hosts about 53,000 internally displaced persons.
Even though the risk factor of urbanization
being a major factor for the spread of disease is
low, the few urban areas have a concentration of
displaced persons and therefore stand a
moderate chance of transmission of highly
infectious diseases such as pandemics (11).
100
80
60
40
20
0
% of Rural Population
% of Urban Population
Figure 4: Urban/Rural Population Distribution per State
4.2.3 Health seeking behavior
The use of health facility for child fever also ranges from state to state. Most mothers in Northern
Bahr El Ghazal (76%) access the health facilities when their children have a fever. The lowest use of
health facilities for child fever is in Upper Nile State (26%). Upper Nile is one of the most affected
conflict states with few numbers of health facilities and restricted movement of the population.
11
Central Equatoria, Western Equatoria, Western Bahr El Ghazal all have less than 50% access to
health facility for child fever (21).
Use of health facilities for Child fevers
76
80
68
70
64
percentage (%)
60
50
50
44
49
48
43
42
40
26
30
20
10
0
Central Eastern Jonglei
Equatoria Equatoria
Lakes
Northern
Bahr El
Ghazal
Unity
Upper
Nile
Warrap Western Western
Bahr El Equatoria
Ghazal
Figure 5: Use of health facilities for Child Fevers
4.2.4 Literacy rate of the population
Figure 6: Literacy Rate per State
12
Literacy rate in South Sudan is generally low.The female literacy rate in South Sudan is highest in
Central Equatoria (59%) and Western Equatoria (57%). All others fall below 50% with the average
of 33% for the whole country. The lowest in Unity state of 11% and Jonglei 19%. This may have
implications for health promotion, hygiene and health care seeking behavior especially during disease
outbreaks and other disasters (11).
4.2.5 Total Weighted Score for Vulnerability
The vulnerability is very high across the country and requires further in-depth analysis. This may be
due to varying socio and economic factors, traditions and other cultural practices.
The results, however, found out that Western Bahr El Ghazal, Central Equatoria and Eastern
Equatoria even though falling below the 50% vulnerability scale were better off than the rest. Jonglei
and Unity states were the two most vulnerable states due to their low coverage of water, sanitation,
hygiene, literacy levels. The graph below shows the comparable vulnerabilities of the ten (10) states.
Figure 7: Total Weighted Score for Vulnerability
13
4.3 Capacity to Respond (Health System)
4.3.1 Structure
There is Epidemic Preparedness and Response Directorate at MoH. This outfit is however poorly
resourced (funding, human expertise). All the states have EPR Task Forces which is not replicated in
the sub level counties.
There are about one thousand and four hundred health facilities ranging from Primary Health Care
Units to hospitals. The health systems capacity, in general, is weak and has a lot of support from UN
Agencies and partner NGOs. There are about forty-nine (49) state and county hospitals across the
country. PHCC is about 206, PHCU being the majority, 997 units. Of the 49 hospitals, only 14 is
capable of providing a comprehensive including basic surgery and emergency obstetrics care(12,16).
The capacity of the system also is very sensitive to other external threats, especially insecurity. For
example, prior to the current crises, there were sixty (60) humanitarian partners across the country
supporting the health system .The number of these humanitarian partners reduced to ten (10) at the
peak of the renewed crises. The number of partners and their locations prior to the July conflict,
during the peak of the crises and 9 weeks after crises (10).
Figure 8: Trend of Partners' Presence before, during and immediately after the July 2016 crisis
Only Juba Central Equatoria), Wau (Western Bahr El Ghazal) and Nasir (Upper Nile) had some
partner NGOs had at least three or four partner presence in these counties. The rest of the counties
have less than two humanitarian partners responding to their health needs. There is no information in
32 counties. Thus in times of disasters coupled with insecurity, the system will not be able to
respond.
14
4.3.2 Services delivery
Table 2: Coverage of ANC 4+ visit and Supervised Delivery,
2016
Supervised
4.3.2.1 ANC services Supervised delivery and in
States
ANC 4+ Visits
Delivery
the states of South Sudan
Central Equatoria
21%
15%
The average percentage of supervised delivery in
Eastern Equatoria
12%
8%
South Sudan is 12.3 percent. The average for four
Jonglei
6%
3%
or more antenatal clinic visits is 19.8 percent.
Lakes
20%
9%
These are far below the respective targets of 73
Northern
Bahr
El
Ghazal
29%
9%
and 60 percent as per the Abuja declaration of
Unity
8%
3%
RBM. Only three out of the ten states namely
Upper Nile
9%
3%
Central Equatoria, Western Bahr El Ghazal, and
Warrap
Western Equatoria have more than the national
22%
8%
average. Western Equatoria, Central Equatoria, Western Bahr El Ghazal
25%
20%
Lakes and the Warrap States have higher than the
Western Equatoria
44%
23%
national average. It can, therefore, be deduced that
utilization of health services is far below the recommended standards in states. The conflict affected
states namely Jonglei, Upper Nile and Unity scored the lowest for heath service delivery (13).
4.3.2.2 Immunization coverage for children under five years
Immunization Coverage in Public Health Facilities
The national immunization coverage for
the following antigens is: Measles is
20.6%, 14.1%. The highest coverage for
these antigens is in Warrap State which is
above 45%. The lowest coverage is found
in Jonglei and Unity States. Equally very
low are Northern El Bahr Ghazal and
Upper Nile (24).
Percentage
60
40
20
0
Penta3 (%)
Measles Coverage (%)
Polio3 Coverage (%)
Figure 9: Immunisation Coverage, 2016
4.3.3 Funding
As was stated earlier the total health budget is less than 4% of the national budget which is
inadequate to sustain government health care delivery in the public sector and also respond to public
health emergencies.
15
4.3.4 Total Weighted Score for Capacity to Respond (Health Systems)
Figure 10: Total Weighted Score for Capacity to Respond (Health System)
From the analysis, the coping capacity of the health system is very weak and very sensitive to
conflicts. The analysis revealed that all the capacity for the health sector to cope with any public
health emergency alone is below the 50% benchmark of the scale. However, Central Equatoria had
some capacity to manage and respond to health risks. The states with the least capacity are Unity,
Northern Bahr El Ghazal and Western Bahr El Ghazal.
During diseases outbreak of high case fatality, these states will require the support of health sector
partners to manage cases. For vaccine preventable diseases, it will be important to strengthen the
whole health service delivery system including cold chain among others.
16
4.4 Composite Public Health Risk
The likelihood of public health risk following the recurring crisis and based on the
assessment of hazards, vulnerability and capacity to respond is generally high. Unity state
has very high composite public health risk; Jonglei and Northern Bahr El Ghazal, high
composite public health risk, all others except Central Equatoria have moderate composite
public health risk as shown in the figure 11 below.
Figure 11: Total Composite Weighted Risk
17
5.0 Conclusion and Recommendation
6.1 Conclusion
The public health risk of the situation in South Sudan is grim with the exposure of millions of
displaced and unserved populations to multiple hazards, vulnerabilities and very weak
system capacity to respond to disasters and outbreaks should they occur. The political and
socio-economic underpins coupled with fragile health system have created complex
challenges requiring an out-of-the-box approach for the implementation of high impact
interventions to mitigate threats.
6.1.2 Hazards
The entire country is highly burdened with multiple hazards. There are all types of hazards,
natural and man-made. Among the diseases of epidemic potential include: cholera, malaria,
measles and hemorrhagic fevers. Conflicts, floods, and food insecurity due to a combination
of hazards are also present. In addition, the presence of explosive remnants of war
complicates the situation.
6.1.3 Vulnerability
The vulnerability of the population considering literacy, health seeking behaviour,
urbanization and displacement, water and sanitation coverage is very high across the
country and requires further in-depth analysis. This may be due to varying socio and
economic factors, traditions, other cultural practices or unavailability or inaccessibility to the
public health sector.
6.1.4 Capacity to Respond
The public health system is also weak and cannot respond to public health emergencies
without external support. The health system is also very sensitive to external shocks and
threats such as conflicts. None of the 10 states has the capacity alone to respond to public
health emergencies.
6.1.5 Composite Public Health risk profile
Even though none of the states independently can respond to health emergencies and
disasters, the overall risks of the states showed that all states in South Sudan are at varying
risks with Unity state at very high public health risk, Jonglei and Northern Bahr El Ghazal at
high risk, Upper Nile, Lakes, Warrap, Western Bahr El Ghazal, Western Equatoria and
Eastern Equatoria at moderate risk, and Central Equatoria at mild risk. The presence of
other security threats like Explosive Remnant of War Jonglei and Upper Nile is likely to
compound response actions in case of a disaster or a major disease outbreak.
6.2 Recommendation
6.2.1: Ministry of Health:
1. Since the risk of occurrence of a disaster is dependent on the hazard, its potential
attack rate and case fatality rates, it will be important to rapidly conduct a hazard
specific risk assessment upon exposure of the vulnerable groups at any given time.
18
This analysis however is aimed at the both the short and medium term interventions
as well as targeted capacity building in the health sector in South
2. There is need to strengthen inter-sectoral approach to public health interventions in
South Sudan to ensure that multiple Government resources can be leveraged for
capacity to mitigate the health hazards. The immediate focus should be on engaging
and involving the key Ministries of: Education, Finance and Water and Sanitation and
Relief and Rehabilitation to guide integration.
3. Even though all the states have EPR Task Forces which is not replicated in the sub
level counties, there is need to review the human resources for health gaps in the
country with the focus on improving on staffing numbers, professional development
and motivation. Mechanisms for staff performance monitoring are non-existent and
needs to be established. The full complement of staffing requirement at the state
level and below to timely detect, plan and respond to and monitor public health
threats is critical.
4. In order to minimize the effects of the hazards, community health intervention
including disease prevention and health promotion activities should be integrated and
scaled up in the country especially in the vulnerable states. These include
communication for development intervention focusing on hygiene and safe water use
and also immunisation and nutrition services. Public health education and health
promotion activities should be emphasized especially in the most vulnerable states.
In times of disease outbreaks, anthropologists and health psychologists will be vital
to understanding the hazard specific practices and recommend response activities.
5. Reinforce and resource the use of the Early Warning Systems in all states in order to
predict and detect promptly any public health threat especially in the states where the
risks are very high This should be done through enhanced coordination and
monitoring of lead agencies and partners assigned to manage the primary health
care services in the states. The periodic analysis provided through the Epi Bulletin is
encouraging but limits effective decision due to low reporting rates from partners as
well as poor national coverage. Despite this, there still remain a wide gap of
community surveillance intervention to help the timely detection and response to
public health threats. There is the urgent need to establish community surveillance
systems through the already promulgated Boma Health Initiative.
6. There is an urgent need to embark on establishing of the health in the life-course
approach to service delivery commencing on development of a more responsive
maternal and child health services. This will increase ante natal and postnatal
services which might lead to the general scaling up of maternal and reproductive
health care services coverage. The development of the Reproductive Maternal
Neonate Infant Child and Adolescent Health and Nutrition Strategy is extremely
important.
7. In order to facilitate the response to any potential disease outbreak and disasters,
there is the need to collaborate with responsible agencies and partners to accelerate
efforts at demining places with Explosive Remnants of War.
19
6.2.2 Humanitarian and Development Partners
1. There is also the urgent need to increase advocacy to the government to increase
health sector funding and resource mobilization in order to accelerate health sector
capacity building.
2. Advocate with the other government sectors and partners providing basic social
services to improve the coverage for water, latrines, and sanitation.
6.2.3. WHO
1. Propose, develop and advocate for technically sound strategy that would bridge the
humanitarian and development needs in the short to medium term. Health Sector
Framework bridging the UNDAF and Humanitarian Response Plan is needed to
leverage commitments and resources mobilization for high impact services. This can
be achieved through the Health Cluster and the Health Sector Development Partners
fora.
2. Strengthen technical guidance on expansion on Early Warning Systems for the
timely detection and responds to public health threats. Focus should be on
strengthening approaches for community surveillance systems.
3. Advocate for health promotion and prevention interventions as a priority in those
states that are at high risk of hazards and are vulnerable.
4. Provide guidance on coordination the development of a life-approach to health
focusing on strengthening maternal and child health services, outbreak and disaster
management and immunisation services.
5. WHO should further facilitate for the conduct of further studies in the cultural,
traditional and health seeking behaviours of the most vulnerable states in order to
address the issues.
20
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