Public Disclosure Authorized

FOR OFFICIAL USE ONLY

Report No: PAD00197

INTERNATIONAL DEVELOPMENT ASSOCIATION

PROJECT APPRAISAL DOCUMENT

Public Disclosure Authorized

ON A
PROPOSED GRANT
IN THE AMOUNT OF SDR 89.1 MILLION
(US$117 MILLION EQUIVALENT)
OF WHICH
SDR 80 MILLION
(US$105 MILLION EQUIVALENT)
FROM THE WINDOW FOR HOST COMMUNITIES AND REFUGEES
Public Disclosure Authorized

TO THE
REPUBLIC OF SOUTH SUDAN

FOR A
SOUTH SUDAN HEALTH SECTOR TRANSFORMATION PROJECT
DECEMBER 6, 2023
Public Disclosure Authorized

Health, Nutrition and Population Global Practice

Eastern and Southern Africa Region

This document has a restricted distribution and may be used by recipients only in the performance of their official
duties. Its contents may not otherwise be disclosed without World Bank authorization.
 CURRENCY EQUIVALENTS

(Exchange Rate Effective Oct 31, 2023)

Currency Unit = South Sudanese Pound (SSP)

SSP 1,040.00 = US$1
US$1 = SDR 0.76
SDR 1 = US$1.31

FISCAL YEAR
January 1 - December 31

Regional Vice President: Victoria Kwakwa

Regional Director: Daniel Dulitzky
Country Director: Ousmane Dione
Practice Manager: Ernest E. Massiah
Amr Elshalakani, Abeyah A. Al-Omair, Moustafa
Task Team Leaders:
Mohamed ElSayed Mohamed Abdalla
 ABBREVIATIONS AND ACRONYMS

ANC Antenatal Care

BEmONC Basic Emergency Obstetric and Newborn Care
BHI Boma Health Initiative
BHW Boma Health Worker
BHT Boma Health Team
BPHNS Basic Package of Health and Nutrition Services
CEmONC Comprehensive Emergency Obstetric and Newborn Care
CEN Country Engagement Note
CERC Contingent Emergency Response Component
CMR Clinical Management of Rape
COVID-19 Coronavirus Disease 2019
CRA Commission for Refugee Affairs
DHIS2 District Health Information Software 2
ESF Environmental and Social Framework
ESMAP Energy Sector Management Assistance Program
ESMF Environmental and Social Management Framework
EU European Union
FCDO Foreign, Commonwealth and Development Office
FCV Fragility, Conflict and Violence
FM Financial Management
Gavi Gavi, the Vaccine Alliance
GBV Gender-based Violence
GCP Global Challenges Program
GDP Gross Domestic Product
GEMS Geo-Enabling for Monitoring and Supervision
GRM Grievance Redress Mechanism
HCI Human Capital Index
HEIS Hands-on Extended Implementation Support
HMIS Health Management Information System
HNP Health, Nutrition, and Population
HPF Health Pooled Fund
HRH Human Resources for Health
HSC High-Level Steering Committee
HSF Health Service Functionality
HSSP Health Sector Strategic Plan
HSTP Health Sector Transformation Project
ICRC International Committee of the Red Cross
IDP Internally Displaced People
IDSR Integrated Disease Surveillance and Response
IEC Information. Education, and Communication
IMF International Monetary Fund
IMNCI Integrated Management of Neonatal and Childhood Illness
IP Implementing Partner
IPC Integrated Food Security Phase Classification
IPF Investment Project Financing
IPV Intimate Partner Violence
M&E Monitoring and Evaluation
MDTF Multi-Donor Trust Fund
MoH Ministry of Health
MoFP Ministry of Finance and Planning
MPA Multiphase Programmatic Approach
NCD Noncommunicable Disease
NDC Nationally Determined Contribution
NGO Non-governmental Organization
NTD Neglected Tropical Disease
OSC Operational Steering Committee
PDO Project Development Objective
PIM Project Implementation Manual
PMU Project Management Unit
PSA Pharmaceutical Supply Agent
SDTF Single-Donor Trust Fund
SEA/SH Sexual Exploitation and Abuse/Sexual Harassment
SEP Stakeholder Engagement Plan
SGBV Sexual and Gender-Based Violence
SMoH State Ministry of Health
SRH Sexual and Reproductive Health
ToR Terms of Reference
UNHCR United Nations High Commissioner for Refugees
UNFPA United Nations Fund for Population Activities
UNICEF United Nations Children’s Fund
WHO World Health Organization
WHR Window for Host Communities and Refugees
 The World Bank
South Sudan Health Sector Transformation Project (HSTP) (P181385)

TABLE OF CONTENTS

DATASHEET ........................................................................................................................................ 2
I. STRATEGIC CONTEXT ................................................................................................................... 9
A. Country Context ............................................................................................................................................... 9
B. Sectoral and Institutional Context ................................................................................................................. 11
C. Relevance to Higher Level Objectives ............................................................................................................ 13
II. PROJECT DESCRIPTION............................................................................................................... 14
A. Project Development Objective ..................................................................................................................... 14
B. Project Components ...................................................................................................................................... 15
C. Project Beneficiaries ...................................................................................................................................... 21
D. Results Chain.................................................................................................................................................. 21
E. Rationale for Bank Involvement and Role of Partners ................................................................................... 22
F. Lessons Learned and Reflected in the Project Design .................................................................................... 23
III. IMPLEMENTATION ARRANGEMENTS ......................................................................................... 23
A. Institutional and Implementation Arrangements .......................................................................................... 24
B. Results Monitoring and Evaluation Arrangements ........................................................................................ 25
C. Sustainability .................................................................................................................................................. 26
IV. PROJECT APPRAISAL SUMMARY ................................................................................................ 26
A. Technical, Economic Analysis ........................................................................................................................ 26
B. Fiduciary ......................................................................................................................................................... 28
C. Legal Operational Policies .............................................................................................................................. 29
D. Environmental and Social .............................................................................................................................. 30
V. GRIEVANCE REDRESS SERVICES .................................................................................................. 32
VI. KEY RISKS................................................................................................................................... 32
VII. RESULTS FRAMEWORK AND MONITORING ................................................................................ 36
ANNEX 1: Implementation Arrangements and Support Plan .............................................................. 53
ANNEX 2: Third Party Monitoring and Data Visualization .................................................................. 61
ANNEX 3: Project Financing Sources by Component .......................................................................... 62
ANNEX 4: Refugees and Host Communities ....................................................................................... 63
ANNEX 5: Estimated Financial Contribution to the Program by Different Partners ............................. 68

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South Sudan Health Sector Transformation Project (HSTP) (P181385)

@#&OPS~Doctype~OPS^dynamics@padbasicinformation#doctemplate
DATASHEET

BASIC INFORMATION

Project
Operation Name
Beneficiary(ies)
South Sudan South Sudan Health Sector Transformation Project (HSTP)
Environmental and Social Risk
Operation ID Financing Instrument Process
Classification
Investment Project
P181385 High Track II
Financing (IPF)

@#&OPS~Doctype~OPS^dynamics@padprocessing#doctemplate
Financing & Implementation Modalities
[ ] Multiphase Programmatic Approach (MPA) [✓] Contingent Emergency Response Component (CERC)
[ ] Series of Projects (SOP) [✓] Fragile State(s)
[ ] Performance-Based Conditions (PBCs) [ ] Small State(s)
[ ] Financial Intermediaries (FI) [ ] Fragile within a non-fragile Country
[ ] Project-Based Guarantee [✓] Conflict
[ ] Deferred Drawdown [✓] Responding to Natural or Man-made Disaster
[ ] Alternative Procurement Arrangements (APA) [✓] Hands-on Expanded Implementation Support (HEIS)

Expected Approval Date Expected Closing Date

20-Dec-2023 31-Jul-2027
Bank/IFC Collaboration
No

Proposed Development Objective(s)

To expand access to a basic package of health and nutrition services, improve health sector stewardship, and
strengthen the health system.

Components
Component Name Cost (US$)

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South Sudan Health Sector Transformation Project (HSTP) (P181385)

Component 1: Provision of Basic Health Services Nationwide 100,710,000.00

Component 2: Health Systems Strengthening 5,500,000.00
Component 3: Monitoring and Evaluation and Project Management 10,790,000.00
Component 4: Contingent Emergency Response Component 0.00

@#&OPS~Doctype~OPS^dynamics@padborrower#doctemplate
Organizations
Borrower: Republic of South Sudan
Implementing Agency: Ministry of Health

@#&OPS~Doctype~OPS^dynamics@padfinancingsummary#doctemplate
PROJECT FINANCING DATA (US$, Millions)

Maximizing Finance for Development

Is this an MFD-Enabling Project (MFD-EP)? No

Is this project Private Capital Enabling (PCE)? No

SUMMARY

Total Operation Cost 369.50

Total Financing 127.00

of which IBRD/IDA 117.00

Financing Gap 242.50

DETAILS

World Bank Group Financing

International Development Association (IDA) 117.00

IDA Grant 117.00

Non-World Bank Group Financing

Counterpart Funding 10.00

Borrower/Recipient 10.00

IDA Resources (US$, Millions)

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South Sudan Health Sector Transformation Project (HSTP) (P181385)

Guarantee
Credit Amount Grant Amount SML Amount Total Amount
Amount

National
Performance-Based 0.00 12.00 0.00 0.00 12.00
Allocations (PBA)

Window for Host

Communities and 0.00 105.00 0.00 0.00 105.00
Refugees (WHR)

Total 0.00 117.00 0.00 0.00 117.00

@#&OPS~Doctype~OPS^dynamics@paddisbursementprojection#doctemplate
Expected Disbursements (US$, Millions)
WB Fiscal Year 2024 2025 2026 2027
Annual 30.00 60.00 27.00 0.00
Cumulative 30.00 90.00 117.00 117.00

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PRACTICE AREA(S)

Practice Area (Lead) Contributing Practice Areas

Health, Nutrition & Population

CLIMATE

Climate Change and Disaster Screening

Yes, it has been screened and the results are discussed in the Operation Document

@#&OPS~Doctype~OPS^dynamics@padrisk#doctemplate
SYSTEMATIC OPERATIONS RISK- RATING TOOL (SORT)

Risk Category Rating

1. Political and Governance ⚫ High

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South Sudan Health Sector Transformation Project (HSTP) (P181385)

2. Macroeconomic ⚫ High
3. Sector Strategies and Policies ⚫ Substantial
4. Technical Design of Project or Program ⚫ High
5. Institutional Capacity for Implementation and Sustainability ⚫ High
6. Fiduciary ⚫ Substantial
7. Environment and Social ⚫ High
8. Stakeholders ⚫ High
9. Other ⚫ Substantial
10. Overall ⚫ High

@#&OPS~Doctype~OPS^dynamics@padcompliance#doctemplate
POLICY COMPLIANCE

Policy
Does the project depart from the CPF in content or in other significant respects?
[ ] Yes [✓] No

Does the project require any waivers of Bank policies?

[ ] Yes [✓] No

ENVIRONMENTAL AND SOCIAL

Environmental and Social Standards Relevance Given its Context at the Time of Appraisal
E & S Standards Relevance
ESS 1: Assessment and Management of Environmental and Social Risks and
Relevant
Impacts
ESS 10: Stakeholder Engagement and Information Disclosure Relevant
ESS 2: Labor and Working Conditions Relevant
ESS 3: Resource Efficiency and Pollution Prevention and Management Relevant
ESS 4: Community Health and Safety Relevant
ESS 5: Land Acquisition, Restrictions on Land Use and Involuntary Resettlement Relevant
ESS 6: Biodiversity Conservation and Sustainable Management of Living Natural
Relevant
Resources

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South Sudan Health Sector Transformation Project (HSTP) (P181385)

ESS 7: Indigenous Peoples/Sub-Saharan African Historically Underserved

Relevant
Traditional Local Communities
ESS 8: Cultural Heritage Relevant
ESS 9: Financial Intermediaries Not Currently Relevant
NOTE: For further information regarding the World Bank’s due diligence assessment of the Project’s potential
environmental and social risks and impacts, please refer to the Project’s Appraisal Environmental and Social Review
Summary (ESRS).

@#&OPS~Doctype~OPS^dynamics@padlegalcovenants#doctemplate
LEGAL
Legal Covenants
Sections and Description
Schedule 2, Section I.A.1. The Recipient shall, not later than thirty (30) days after the Effective Date, establish and
thereafter maintain, throughout the Project implementation period, with composition, mandate and resources
satisfactory to the Association, a high level steering committee, to be chaired by the Ministry of Health and co-shared
by the Ministry of Finance and comprised of representatives of key stakeholders to be responsible for providing overall
guidance and strategic support to the Project.
Schedule 2, Section I.A.2. The Recipient shall establish, not later than thirty (30) days after the Effective Date, an
Operational Steering Committee with a composition, mandate, resources and functions satisfactory to the Association,
and thereafter maintain such OSC at all times during the implementation of the Project, to be responsible for, inter alia,
providing advice on technical aspects of Project activities, follow up the progress in achieving the targets identified in
the results framework and monitoring and evaluation plans, as detailed in the Project Implementation Manual (PIM).
Schedule 2, Section I.A.3.(d). Without limitation to Section I.A.3 (a) of Schedule 2, the environmental specialist and
social specialist shall be appointed and recruited not later than sixty (60) days after Effective Date.
Schedule 2, Section I.B.1. The Recipient shall, no later than thirty (30) days after the Effective Date, through the Ministry
of Health, prepare in accordance with terms of reference acceptable to the Association and furnish to the Association
for prior review a Project Implementation Manual for the Project
Schedule 2, Section I.B.2.(a). The Recipient shall, no later than thirty (30) days after the Effective Date, through the
Ministry of Health, prepare in accordance with terms of reference acceptable to the Association and furnish to the
Association for prior review a Project Procurement Manual for the Project, which shall include provisions on the
procurement management procedures
Schedule 2, Section I.B.3.(a). The Recipient shall, not later than thirty (30) days after the Effective Date, (and thereafter
by February 15 of each subsequent FY) prepare and furnish to the Association, a work plan and budget containing all
activities proposed for implementation in the following calendar year.
Schedule 2, Section I.C. Within one hundred eighty days (180) days from the Effective Date, or such later date as agreed
by the Association, the Recipient shall recruit and maintain throughout Project implementation, the Third-Party
Monitoring Agent, in accordance with terms of reference satisfactory to the Association, to monitor and review
performance of the Project.
Schedule 2, Section I.D. The Recipient shall, not later than sixty (60) days after the Effective Date, establish and
thereafter maintain at all times during the implementation of the Project, a Grievance Mechanism, under terms and
structure satisfactory to the Association.

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South Sudan Health Sector Transformation Project (HSTP) (P181385)

Schedule 2, Section I.E.1.(a)(i) Without limitation upon the provisions of Section I.A of this Schedule 2, the Recipient
shall, through its PMU, not later than sixty (60) days after the Effective Date, make part of the proceeds of the Financing
allocated from time to time to Category (1) of the table set forth in Section III.A of this Schedule, available to UNICEF
under an output arrangement on terms and conditions approved by the Association, as further elaborated in the PIM
Schedule 2, Section I.E.1.(b)(i) Without limitation upon the provisions of Section I.A of this Schedule 2, the Recipient
shall, through its PMU, not later than sixty (60) days after the Effective Date, make part of the proceeds of the Financing
allocated from time to time to Category (2) of the table set forth in Section III.A of this Schedule, available to WHO
under an output arrangement on terms and conditions approved by the Association, as further elaborated in the PIM.
Schedule 2, Section II.1. The Recipient shall furnish to the Association each Project Report (i.e., a progress Project
Report providing for a summary of activities covering a period of six (6) calendar months, and a detailed annual Project
Report), not later than forty-five (45) days after the end of the period covered by such report.
Schedule 2, Section II.2. The Recipient shall ensure that each Third-Party Monitoring Report from the Third-Party
Monitoring Agent, prepared in accordance with terms of reference acceptable to the Association is furnished to the
Association within sixty (60) days of the end of the period covered by said report

@#&OPS~Doctype~OPS^dynamics@padconditions#doctemplate
Conditions
Type Citation Description Financing Source
The MDTF Agreement has
been executed and
delivered and all conditions
precedent to its
effectiveness or to the right
Effectiveness Article V, 5.01.(a) IBRD/IDA
of the Recipient to make
withdrawals under it (other
than the effectiveness of
this Agreement) have been
fulfilled.
The Association is satisfied
that the Recipient has an
Effectiveness Article V, 5.01.(b) IBRD/IDA
adequate refugee
protection framework.
The Recipient has
established the Project
Management Unit in
accordance with the
provisions of Section I.A.3
Effectiveness Article V, 5.01.(c) of Schedule 2 to this IBRD/IDA
Agreement and recruited
its key staff, namely (i) a
Project Manager, (ii) a
financial management
specialist, and a (iii) a

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South Sudan Health Sector Transformation Project (HSTP) (P181385)

procurement specialist;
each on the basis of terms
of reference, qualification,
integrity, and experience
acceptable to the
Association.
the Recipient has prepared,
disclosed, consulted upon
and adopted the ESMF,
Effectiveness Article V, 5.01.(d) LMP, RF, SRAMP all under IBRD/IDA
terms satisfactory to the
Association and in
accordance with the ESCP.

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

I. STRATEGIC CONTEXT

A. Country Context
1. The history of South Sudan has been marked with bouts of conflict and efforts for peace and stability. After
prolonged armed conflict with northern Sudan and the Comprehensive Peace Agreement in 2005, the Republic of
South Sudan emerged as the world’s youngest country in 2011. In 2013, a civil war erupted in the nascent country,
which ended with the signing of the Revitalized Agreement on the Resolution of the Conflict in the Republic of
South Sudan (R-ARCSS). As a result of consecutive wars, the country has experienced only about 15 years of peace
since 1955, specifically during 1972–1982 and 2005–2011. While a series of encouraging reforms have been
undertaken to support longer-term stability and development outcomes, the country continues to struggle with
the lingering impact of prolonged conflict, including widespread levels of poverty, elevated violence in several
areas, weakened institutions, untapped human capital, lack of access to basic services, food insecurity, and a non-
diversified economy.
2. South Sudan is one of the poorest countries in the world with over 80 percent of people living in poverty. South
Sudan’s GDP is estimated to have contracted by 0.4 percent in FY 2022/23,1 weighed down by a fourth consecutive
year of flooding, lingering impacts of the COVID-19 pandemic, violence flareups, and higher food inflation due to
global crises.3 The 2022 Household Budget Survey estimates that poverty levels in South Sudan remain persistently
high–at around 80 percent of the population, with 6 in 10 South Sudanese living in extreme poverty (below the
food poverty line). Nearly 80 percent of South Sudan’s population lives in rural areas where infrastructure is
limited, complicating service delivery, particularly during the rainy season.
3. South Sudan has the highest level of vulnerability and lowest level of climate adaptation capacity globally, based
on the European Union’s 2022 INFORM Risk Index.2 South Sudan, composed entirely of river basins, ranks as the
seventh most vulnerable country to riverine flood in the world in an average year.3 Between 2019 and 2022, the
flooding reached record levels with climate change affecting weather patterns, destroying already scarce
infrastructure, displacing populations, and decreasing movement throughout the country. It is estimated that 1
million people were affected by flooding and 300,000 people were displaced in 2021. South Sudan also
experiences an intense annual hot season and cyclical drought. This extreme vulnerability to flooding and drought,
coupled with the primarily rural landscape has made the delivery of services very difficult.
4. Women and girls face a disproportionate burden of poverty, poor access to services, and insecurity. Just over
51 percent of women are married by age 184 and the total fertility rate is 4.47 births per woman5. Additionally,
around one-third of girls become pregnant before the age of 15. Women and girls also face a disproportionate
burden of violence. While violence takes multiple forms, intimate partner violence (IPV) is significant with 26.7
percent of ever-partnered women having experienced IPV in the past year.5

1
World Bank. Macro Poverty Indicator, October 2023.
2 Inform Risk Index, 2024: https://www.worldbank.org/en/news/immersive-story/2023/04/25/water-security-and-fragility-insights-from-south-
sudan; and World Bank, Global Water Security and Sanitation Partnership, Rising from the Depths: Water Security and Fragility in South Sudan; May
2023. https://www.worldbank.org/en/news/immersive-story/2023/04/25/water-security-and-fragility-insights-from-south-sudan.
3 The country is composed of the Bahr el Ghazal, Bahr el Jebel, and Baro-Akobo-Sobat River Basins, which converge into a fourth, the Upper Nile

River basin, which lace the country with a network of rivers and tributaries that flood annually. World Bank, Global Water Security and Sanitation
Partnership, Rising from the Depths: Water Security and Fragility in South Sudan; May 2023. https://www.worldbank.org/en/news/immersive-
story/2023/04/25/water-security-and-fragility-insights-from-south-sudan.
4 UNICEF. (2020, October). Some things are not fit for children – marriage is one of them. South Sudan. Retrieved from

https://www.unicef.org/southsudan/press-releases/some-things-are-not-fit-for-children
5UNFPA. South Sudan. https://southsudan.unfpa.org/en/topics/family-planning-20

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5. More resources need to be mobilized to meet the immediate needs of refugees arriving in South Sudan. With
hundreds of thousands of South Sudanese already internally displaced due to other conflicts, flooding, and food
insecurity, many northern border areas receiving Sudanese refugees were already under stress before the Sudan
conflict broke out on April 15, 2023. According to the United Nations High Commissioner for Refugees (UNHCR)
data as of September 30, 2023, South Sudan hosted 333,300 refugees and 74,576 households with the vast
majority–89 percent–in two locations: Jamjang in Pariang County in the Ruweng Administrative Area and Bunj
Town in Maban County in Upper Nile State.6 The Sudanese refugee population is by far the largest, with 311,160
individuals, or 93 percent of the hosted population while the rest come from the Democratic Republic of Congo,
Ethiopia, the Central African Republic, Burundi, and Somalia. Almost 52 percent of the refugees are female, with
women and children representing 81 percent of the refugee population. About 60 percent of refugees are under
18 years, with 38 percent between 18 and 59 years and the rest over 60 years.
6. The history of continued conflicts–both within South Sudan and in neighboring countries–has resulted in a
significant number of refugees, asylum seekers, and internally displaced persons (IDPs) and created refugee
camps and IDP settlements across the country. The prospect of these refugees returning to their countries of
origin in the near term is limited, and the trauma endured, assets lost, and livelihoods destroyed in fleeing conflict
in the host country have created unique development challenges for refugees in reestablishing their lives in South
Sudan. For instance, refugees are at much higher risk of infectious diseases and malnutrition. In Renk alone, a
measles outbreak has left 59 children dead as of September 15, 2023. Malaria cases are also on the rise,
accounting for 40 percent of all medical consultations in Renk. It is estimated that acute malnutrition rate among
refugees in South Sudan is as high as 31.1 percent for children under the age of 5, and 63.4 percent for pregnant
and lactating women7.
7. Despite these challenges, refugees often have better access to basic services and support such as health,
education, and food rations in refugee camps administered by UNHCR than members of host communities, who
tend to live in isolated areas where government services and market-based opportunities are either highly limited
or non-existent. For this reason, UNHCR makes specific efforts to support host communities, to the extent that
resources allow. The onset of the crisis in Sudan and the large number of arrivals in northern border areas have
further exacerbated the need for resources addressing interventions around forced displacement in the country.
With most of the humanitarian agencies scaling down their support in the country, the project will need to play a
more significant role to fill the gap.
8. The Government of South Sudan has maintained an open-door policy and reaffirmed its commitment to address
vulnerabilities and respond to shocks for both refugees and host communities. South Sudan is recognized as
having one of the most progressive refugee policy frameworks in Eastern Africa. It has acceded to the 1951
Refugee Convention and its 1967 Protocol, as well as the 1969 Organization of African Union Convention
Governing the Specific Aspects of Refugee Problems in Africa. South Sudan is also a state party to several other
international and regional human rights instruments relevant to the protection of refugees and has adopted the
draft East African Community Refugee Management Policy. The Refugee Act of 2012, which provides the central
legal framework for refugee protection in South Sudan, incorporates provisions that are in line with international
and regional treaties. The Government has also maintained a policy of granting refugees access to its territory,
land for cultivation and livelihoods, and practical arrangements for their initial reception and registration.
Refugees are granted freedom of movement and, in principle, are free to settle anywhere in the country. The
Commission for Refugee Affairs (CRA) plays the leading role in developing government policy on refugee issues,

6 UNHCR Operational Data Portal https://data.unhcr.org/en/country/ssd.

7
UNHCR. September 2023. Health and Nutrition Update. Sudan Situation.

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

B. Sectoral and Institutional Context

Health Sector Outcomes
9. South Sudan faces significant challenges that adversely affect its human capital with one of the lowest Human
Capital Index (HCI)8 scores at 0.31 (2020)9 In the country, 31 out of every 100 children are stunted, increasing the
risk of physical and cognitive impairment, which can ultimately affect the adult survival rate. South Sudan’s health
outcomes rank among the poorest in the world. As of 2021, life expectancy at birth is one of the lowest in the
world, estimated at 54.98 years, and the under-five mortality rate was 98.69 per 1,000 live births from 2017 to
2021.10 The country has the highest neonatal mortality globally at 39.63 per 1,000 live births.11 About 71 percent
of the population residing over 5 km from the nearest health facility. South Sudan has the highest maternal
mortality ratio globally at 1,223 per 100,000 live births.12 Notably, only 38 percent of facilities offering
Comprehensive Emergency Obstetric and Newborn Care (CEmONC)13 are partially functional and caesarian
sections are only available in major urban areas, accounting for only 1 percent of all deliveries, much lower than
the expected rate of necessary caesarian sections at around 10–15 percent.
10. Cultural norms and a preference for larger families dampen the demand for reproductive and maternal health
services. Even when women show interest in family planning, they often encounter barriers to access.14 The
combination of a contraceptive prevalence rate of only 6 percent,15 persistent high fertility rates, and challenges
like early marriage precipitate adolescent childbearing. One in three adolescent girls in South Sudan have begun
childbearing, which increases the risk of maternal mortality and childbirth injuries like obstetric fistula.16
11. Acute malnutrition remains a major public health emergency in South Sudan. As of November 2023, 5.8 million
people,17 or over half of South Sudan’s population, experienced high levels of acute food insecurity, classified as
crisis (Integrated Food Security Phase Classification, IPC Phase 3). Of those, 1.6 million people are experiencing
emergency condition (IPC Phase 4) acute food insecurity and an estimated 35,000 people in catastrophe (IPC
Phase 5) acute food insecurity in Fangak, Canal/Pigi and Akobo of Jonglei State; Pibor County in the Greater Pibor
Administrative Area.
12. The country grapples with frequent disease outbreaks exacerbated by conflict, persistent seasonal flooding,
inadequate sanitation and water infrastructure, a fragile health system, and low vaccination coverage.
Preventable and curable climate sensitive diseases, such as malaria and cholera, are leading causes of death in
the country. WHO and the United Nations Children’s Fund (UNICEF) estimate that only 76 percent of children
receive the Pentavalent 3 vaccine.18 The country also has one of Africa’s lowest measles immunization coverage

8 World Bank. Human Capital Index, 2020.

9 The HCI uses two primary health indicators: the stunting rate in children under the age of 5; and the adult survival rate.
10 World Bank. World Development Indicators. https://databank.worldbank.org/id/fef9176d?Report_Name=Macroeconomics-Workshop.
11 World Bank. Mortality Rate – Neonatal: South Sudan. https://data.worldbank.org/indicator/SH.DYN.NMRT?locations=SS.
12 World Bank. Maternal Mortality Ratio. https://data.worldbank.org/indicator/SH.STA.MMRT?locations=SS.
13 World Bank. Empowering Girls and Women in South Sudan. 2022.
14 Lawry et al. 2017; World Bank. Empowering Girls and Women in South Sudan. 2022.
15 UNFPA. 2023. Family Planning. https://southsudan.unfpa.org/en/topics/family-planning-
16 World Bank. Empowering Girls and Women in South Sudan. 2022.
17 IPC. November 6, 2023. IPC Acute Food Insecurity and Malnutrition Analysis for September 2023—July 2024 for South Sudan.
18 Draft South Sudan Health Sector Strategic Plan 2023-2027.

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estimated at 49 percent for the first dose of the measles vaccine,19 while a 95 percent coverage rate is needed to
substantially reduce transmission.20 Additionally, the 2017 EPI coverage survey estimated that only 18.9 percent
of children are fully immunized, contributing to the high levels of vaccine preventable diseases.21
Health System and Service Delivery Challenges
13. Substantial supply- and demand-side health service delivery challenges persist across all health services. Supply-
side issues include limited physical infrastructure, supply stock-outs, severe health service delivery capacity gaps,
and a long history of suboptimal health service delivery. While historically, the focus has been on supply-side
challenges, demand-side issues require equal attention. The Boma22 Health Initiative (BHI),23 is a community
health worker program, targeting these issues by improving community-level interventions and bridging the gap
between health service supply and demand.
14. Health and health service delivery in South Sudan are intertwined with climate change and the country’s
climatic patterns. The heavy annual flooding in the country disrupts ground transportation annually, rendering
road transport to most rural areas impossible and severely restricting air transport. As a result, supply lines are
cut off and staff movements are difficult. Patient travel to facilities, which is by foot in most areas year-round, is
further hampered. Simultaneously, transmission of waterborne and vector-borne diseases increases annually
during this period, causing spikes in diarrheal diseases and malaria, which account for 8.59 and 8.07 percent of
the country’s burden of disease, respectively.24
15. The overall response to sexual and gender-based violence (SGBV) remains inadequate in reach, quantity and
quality. There is a severe shortage of medical personnel trained in Clinical Management of Rape (CMR) and basic
psycho-social support is insufficient. Across the country health professionals seldom receive training in counseling
and psycho-social care. Specialized mental health expertise is virtually non-existent, with currently only one South
Sudanese psychiatrist working for the entire country.
16. South Sudan’s health system is characterized by fragmentation and minimal Government engagement. Since
2013, health service delivery has been supported through external financing from the World Bank through UNICEF
and the International Committee of the Red Cross (ICRC) covering three states25 and the European Union (EU),
Gavi the Vaccine Alliance through a consortium led by Crown Agents and bilateral donors including the United
Kingdom (UK), the United States, Canada, and Sweden covering seven states. While donors have strengthened
coordination between the two areas in delivering the same package of services and harmonizing monitoring and
the human resources for health (HRH) incentive scheme, the two areas had separate management structures
creating inefficiencies and coordination challenges.
17. The Government contributes a mere 4 percent of its budget to health, far below the 15 percent target pledged
by the African Union countries in 2001. The health sector has been chronically underfunded since 2013, which
undermines the system’s sustainability. Estimates suggest that household out-of-pocket expenditures on health
account for as high as 79 percent of the total health expenditure. As per the MoFP letter to the World Bank dated
November 23, 2023, the Government of South Sudan will commit USD$ 20 million in support of the proposed

19 World Health Organization. Measles – South Sudan. 10 February 10, 2023. https://www.who.int/emergencies/disease-outbreak-
news/item/2023-DON440#:~:text=South%20Sudan%20is%20one%20of,were%20estimated%20to%20be%2049%25.
20 Gavi. South Sudan launches major push on measles vaccination. 2023. https://www.gavi.org/news/media-room/south-sudan-launches-major-

push-measles-vaccination.
21 Draft South Sudan Health Sector Strategic Plan 2023-2027.
22 A boma is the lowest-level administrative division in South Sudan. Bomas vary in size and typically contain many individual villages.
23 BHI is a national scale community health program that aims to strengthen the health system in South Sudan.
24 UNICEF. Malaria Season: https://www.unicef.org/southsudan/stories/malaria-season.
25
The Republic of South Sudan now has 10 states and 3 administrative areas.

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reforms under the HSTP. This includes: (i) a US$10 million budgetary allocation as a direct co-financing into HSTP;
and (ii) an additional US$10 million provided under the food shock window of the IMF program with South Sudan
that has been disbursed to MoH to procure pharmaceuticals, medical consumables, and equipment. The World
Bank will provide to the Government through an independent Third-Party Monitoring (TPM) a report outlining the
execution and utilization of the funds supported by the IMF program. The MoFP and MoH will provide the required
access and documentation to facilitate the TPM validation.
C. Relevance to Higher Level Objectives
18. The proposed South Sudan Health Sector Transformation Project (HSTP) is aligned with the World Bank’s goals
and regional and global strategies and is poised to contribute to IDA20 policy commitments. Specifically, the
HSTP contributes to the World Bank’s vision to create a world free of poverty on a livable planet, the World Bank
Evolution, and the Eastern and Southern African regional priorities by investing in improved water and sanitation
and energy efficiency in health facilities, strengthening national and state level capacity for climate and health
emergency preparedness and response, and critical nutrition interventions for children and pregnant women. The
IDA20 commitments place special priority on improving overall human capital focus on improving pandemic
prevention and preparedness support building resilient health systems that have the capacity to prevent, detect,
and respond to disease outbreaks and other health emergencies. The project is also fully aligned with the 2023
Dar es Salaam declaration on human capital.
19. The project is consistent with the World Bank Group Country Engagement Note (CEN) for South Sudan for
FY2021—2023 (Report No. 158008-SS). The project is aligned with the first and second focus areas of the CEN: (a)
lay groundwork for institution building; and (b) continue support for basic public service delivery. In addition, the
project is in line with the Fragility, Conflict and Violence (FCV) Strategy Pillar 2 on remaining engaged during
conflict and crisis situations, with a direct link to its first high priority area of investing in human capital, as well as
Pillar 4, which centers on mitigating the spillovers of FCV, given that the project will facilitate provision of vaccines
to refugees and IDPs in South Sudan.
20. The project is fully aligned with South Sudan Health Sector Strategic Plan (HSSP 2023—2027) which aims to
improve the health status of people by effective delivery of a basic package of health and nutrition services
(BPHNS) and highlights partnership with donors to support key health sector programs as one of its strategic
objectives. The upcoming National Immunization Strategy will be part of the HSSP.
21. The project is consistent with South Sudan’s Second Nationally Determined Contribution (NDC) and National
Adaptation Plan (NAP), both issued in 2021.26 The NDC details specific health goals while the NAP identifies health
as a priority sector for climate adaptation in South Sudan. Both documents outline activities supported by and
embedded in the project including strengthening surveillance and early outbreak warning systems for climate-
sensitive diseases and climate and health emergencies, building community capacity for climate emergency
preparedness and response, and developing climate resilient health systems.
22. The project complements both World Bank and development partner investments in health systems’
strengthening, disease control and surveillance, interventions to change individual and institutional behavior,
and citizen engagement. The project also supports the attainment of Universal Health Coverage and of the
Sustainable Development Goals, and the promotion of a One Health approach.

26South Sudan’s Health Sector Strategic Plan (HSSP) 2023-2027, with which the project is aligned and is considered the Long-Term Strategy (LTS)
relevant to the project, includes one reference to climate change along with several to the impacts of flood and droughts and no climate change
specific actions. Therefore, the project is considered consistent with the HSSP for Paris Alignment.

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

II. PROJECT DESCRIPTION

24. The project will operate in all ten states and three administrative areas of South Sudan and is designed to expand
access to a basic package of health and nutrition services for the people in South Sudan, including refugees, with
financial support available and future financing over the immediate- and short-term. The project design outlines
project activities that will be implemented with an initial funding envelope that comprises an IDA grant of US$12
million equivalent and a grant from the IDA20 WHR of US$105 million equivalent. Additional resources totaling
US$242.5 million are expected to be mobilized as donor funding through a Multi-Donor Trust Fund (MDTF) and a
Single-Donor Trust Fund (SDTF) during the period of January to September 2024. The project will provide US$16
million in retroactive financing to cover the advanced procurement and staffing costs incurred by UNICEF for
project preparation.

25. The project is being processed under the World Bank Policy for IPF, paragraph 12. The Government of South
Sudan requested the World Bank, in letters dated August 14, 2018, and January 27, 2020, to provide financing
directly to organizations to carry out operations for the benefit of the people in South Sudan, due to capacity
constraints of the Government to effectively manage and implement operations. The project seeks to build the
MoH’s institutional capacity to pave the way for the future World Bank-financed projects in South Sudan to
transition toward a fully government-led implementation modality where the MoH’s role in service delivery will
be to contract and manage service providers.
A. Project Development Objective
PDO Statement
The Project Development Objective (PDO) is to expand access to a basic package of health and nutrition services,
improve health sector stewardship, and strengthen the health system.

PDO-Level Indicators

• Percentage of bomas covered by the Boma Health Initiative

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

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• Percentage of MoH budget executed

• General service availability score (Percentage)
o General service availability score for refugees (Percentage)
o General service availability score for host community areas (Percentage)

B. Project Components
26. Component 1: Provision of Basic Health Services Nationwide (UNICEF and competitively selected
pharmaceutical procurement and logistics will implement; US$330.77 million: US$10 million equivalent from
Government contribution; US$100.71 million equivalent IDA [including US$90.49 million WHR] and US$220.06
million Trust Funds [US$23.14 million SDTF and US$196.92 million MDTF]). Component 1 will deliver basic health
services nationwide, guided by the MoH’s HSSP and building on the experiences obtained under the COVID-19
Emergency Response and Health System Preparedness Project (CERHSPP-P176480) and the Health Pooled Fund
(HPF), with a focus on improving service availability including to refugees and host communities. It will deliver a
selection of prioritized services from the BPHNS: child health; nutrition; maternal and neonatal health; Basic and
Comprehensive Emergency Obstetric and Newborn Care (BEmONC and CEmONC); family planning and sexual and
reproductive health services; SGBV services; mental health; disability; infectious and noncommunicable diseases;
emergency and surgical services; Social and Behavior Change Communication (SBCC), health promotion, and
education; and strengthened referral systems. Special emphasis will be given to improving childhood vaccination
and malaria prevention, diagnosis and treatment, with targeted services to refugees and host communities.
27. The project will expand access to health services for host communities and refugees (in addition to Maban and
Jamjang which received support under previous WHR-funded health projects), remote and rural populations,
women, and other marginalized groups.27 The project will implement several mechanisms to target refugees and
host communities (HC) and address their unique challenges in accessing health services, including strengthening
community health programs and health promotion activities in refugee and host communities areas. It will
incorporate climate-sensitive planning and service delivery to mitigate the health impacts of climate change and
climatic shocks. Conflict-sensitive approaches will be used to ensure equitable access to services.28 Expanded
access to the package of health services will be delivered at the community level through the BHI and primary
care facilities along with strategically identified secondary and tertiary hospitals, complemented with community
outreach and mobile health services to increase, and expand equitable service access for the population. The
component will also strengthen the health system by enhancing the pharmaceutical supply chain, improving
health management information system (HMIS) data collection, quality improvement at the facility and county
level, climate-sensitive health facility rehabilitation, and health worker training.
28. Through Subcomponents 1.1 and 1.2, UNICEF will contract implementing partners (IPs) to deliver health services
across designated geographic areas, or Lots. Contracting national non-governmental organizations (NGOs)
directly, reducing reliance on consortiums to maximize fund flows for health service delivery, will be emphasized.
The two subcomponents will be executed in collaboration with and under the leadership of the MoH, State
Ministries of Health (SMoHs), and County Health Departments (CHDs). To build the capacity of SMoHs and CHDs,
an integrated approach will be taken to management and supervision, whereby IP staff will be co-located within
CHDs and engage in on-the-job capacity development with the CHDs, primarily through a twinning approach.

27 Other marginalized groups are anticipated to include the people with disabilities (including mental), and in terms of health service access,
adolescents.
28 Conflict sensitivity is woven into the project design.

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UNICEF will station staff at (a) the county level to provide supervision and support for IPs, CHDs, and project
activities; and (b) the state level within the SMoHs to provide on-the-job capacity development for SMoH staff.
29. Subcomponent 1.1: Delivery of High Impact Basic Health and Nutrition Services Nationwide through Health
Facilities (implemented by UNICEF; US$273.73 million: US$10 million equivalent from Government
contribution, US$62.67 million equivalent IDA [WHR] and US$201.06 million Trust Funds [US$21.14 million SDTF
and US$179.92 million MDTF]). This subcomponent will deliver cost-effective, high-impact basic health and
nutrition services through health facilities nationwide, including to refugees and host communities. The
subcomponent aims to cover 1,158 health facilities throughout the life of the project using a phased approach
beginning with 600 health facilities, including 135 in refugee and host community areas, and will expand based on
population coverage and health facility readiness. The subcomponent will also support strengthened supervision,
management, and on-the-job coaching for IPs and service providers through an integrated supervisory approach
in which IPs develop CHD capacity, inclusive of health service delivery planning, supervision, and data entry into
District Health Information Software 2 (DHIS2). The subcomponent will include planning and execution of
outreach (village visits, mass campaigns, and so on) and transportation (vehicle, boat, and foot) modalities paying
close attention to seasonal population movement patterns and access. Climate sensitive health service delivery
and planning will be integral to the approach under this subcomponent.
30. Subcomponent 1.1 will channel resources through UNICEF to sub-contract national and international NGOs for
health service delivery and coordination.29 In collaboration and through the leadership of the MoH, SMoHs, and
CHDs, UNICEF will be responsible for (a) oversight and coordination of health services and DHIS2 data collection
and entry systems; (b) supervision and quality assurance of IPs and health facilities in line with national plans and
guidelines; (c) coordinating and conducting in-service training; (d) through an integrated approach, developing
the capacity of SMoHs to plan, supervise, and oversee service delivery and the DHIS2 system; and (e) integrated
pharmaceutical procurement, quantification, and forecasting. Contracted IPs will be responsible for: (a) delivering
quality health services; (b) quality improvement activities; (c) supervision of health facilities (d) recording of HMIS
data, provision of HMIS data to CHDs, and support for entry of DHIS2 data into DHIS2 and data use; (e) in-service
training complementing UNICEF’s training activities; (f) health facility stock management, recording, and rational
use; (g) through an integrated approach, developing the capacity of CHDs to plan, supervise, and oversee service
delivery and the DHIS2 system; and (h) sustain the support of the innovation activities under CERHSSP and expand
using the digital health technology to address service delivery and supply chain issues.
31. Subcomponent 1.2: Boma Health Initiative (implemented by UNICEF; US$12.41 million: US$3.41 million
equivalent IDA [WHR IDA] and US$9.0 million Trust Funds [US$0.95 million SDTF and US$8.05 million MDTF]).
This subcomponent will invest in expanding and strengthening the BHI to deliver basic health services at the
community level including to refugees and host communities, in the context of South Sudan’s extremely rural,
climate vulnerable, conflict impacted, and dispersed population with limited road access. The subcomponent will
be executed by UNICEF through contracted IPs, in coordination with the leadership of the MoH, SMoH, and CHDs.
The focus on community-based interventions and health promotion activities have been identified as priorities
for refugees and host communities. Continuity of service delivery during the intense annual flooding and high heat
in the country, is a primary impetus for this activity. Specifically, the subcomponent will: (a) finance the delivery
of health services through the BHI; (b) increase the coverage of the BHI based on a needs assessment and timed

29Subcomponent 1.1 will finance costs related to: (a) health service delivery at health facilities and outreach activities; (b) operational costs of health facilities including
staff incentives, utilities, waste management, and transportation; (c) technical supervision, support, monitoring and oversight by UNICEF of sub-contracted NGO
implementing partners; (d) health worker in-service training conducted by UNICEF and NGO implementing partners (IPs); (e) quality assurance and improvement
activities (f) health facility supervision and reporting for sub-contracted IPs; (g) development of IP capacity through an integrated approach; and (h) project management
costs (e.g. transport costs, information technology support, monitoring and reporting) for UNICEF.

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plan, with commensurate increases in the number of Boma Health Supervisors and strengthening of Boma HW
management and training; (c) increase the number of female Boma health workers; (d) develop visual/low-literacy
tools for BHWs; and (e) strengthen supervision, training, supply chain, and support for BHWs. BHWs will deliver
basic preventative and curative services, health education, and refer/ accompany patients to higher levels of care
when needed. Core services to be delivered by BHWs include: health promotion and SBCC; maternal health, child
health including vaccine preventable diseases, family planning, and gender-based violence (GBV); control of
malaria, pneumonia, and diarrhea including diagnostics and treatment for uncomplicated cases; identification and
referral of malnutrition; referral and, as needed, accompaniment for immunization, antenatal care (ANC), and
postnatal care services; and outbreak surveillance, prevention; and response. Multi-level health promotion
interventions will be tailored to the specific needs of vulnerable and hard-to-reach groups particularly refugees
and host communities through increased outreach activities and access to health education by BHI workers, and
will be designed to be understood by all, including women, girls, and other disadvantaged populations who are
illiterate or lack access to information sources. Resources for Subcomponent 1.2 will be channeled through
UNICEF; agencies contracted to deliver health services under Subcomponent 1.1 will also deliver services through
the BHI in the same geographic areas.
32. Subcomponent 1.3: Pharmaceutical and Supply Last Mile Delivery (implemented by UNICEF through a
subcontracted and competitively selected pharmaceutical procurement and logistics agency; US$13.41 million:
US$3.41 million equivalent IDA [WHR] and US$10.0 million Trust Funds [US$1.05 million SDTF and US$8.95
million MDTF]). This subcomponent will finance a pharmaceutical supply agent (PSA) with the aim of improving
the availability of essential medicines at health facilities through strengthened supply systems. The PSA will be
responsible for: (a) country-wide pharmaceutical and medical supply distribution of supplies for health facilities
and BHWs, including to refugees and host community areas; and (b) last mile logistics, including delivery of
medical supplies and pharmaceuticals to health facilities. IPs will be responsible for the storage, stock
management, cold chain management, rational use of pharmaceuticals at health facilities, and distribution of
supplies to BHWs. This subcomponent will incorporate the use of technology to improve the tracking,
quantification, and accountability of pharmaceutical delivery to the last mile. Close attention will be paid to
climate sensitive supply chain, including prepositioning of pharmaceuticals for the rainy season, ensuring all
pharmaceuticals are in the country ahead of the rainy season, ensuring pharmaceuticals and medical supplies are
protected from climate shocks, and acquiring buffer stocks of pharmaceuticals.
33. Subcomponent 1.4: Climate Resilient Health Service Delivery (implemented by UNICEF; US$31.22 million
equivalent IDA [including US$21.00 million WHR]). The subcomponent will enable broad climate change
adaptation through the project with the aim of minimizing the impact of climate change on the population, health
system, and project in light of the immense impact of climate change on South Sudan’s population and health
system, through targeted investments. The subcomponent will be closely coordinated with the Climate Resilient
Flood Management Project (P179169) and the South Sudan Energy Sector Access and Institutional Strengthening
Project (P178891) as well as with UN agencies such as UNICEF. The subcomponent will finance: (a) water and
sanitation improvements in facilities to improve infection prevention and control, with a focus on reducing the
transmission of climate sensitive (water and vector borne) diseases and addressing the impacts of flooding on
water and sanitation in health facilities; (b) minor rehabilitation30 to health facilities selected based on their
exposure to climate shocks to reduce the impact of these shocks, primarily flooding and high heat, and implement
energy efficiency improvements; (c) minor rehabilitation of pharmaceutical stores to effectively and securely
preposition pharmaceuticals for rainy season; (d) limited solar electrification of health facilities to complement to

30Minor civil works and rehabilitation in the context of the HSTP means the construction work that will be undertaken in existing structures of project-supported health
care facilities and pharmaceutical stores, which will not in any way alter the structural designs of the facilities and stores. These works also require no prior municipality
or planning approval. They will result in little to no environmental or social impact.

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those financed by the South Sudan Energy Sector Access and Institutional Strengthening Project(P178891); (e) the
development and dissemination of climate adaptive and energy efficient health facility and pharmaceutical store
rehabilitation guidelines to inform current and future climate sensitive rehabilitation; (f) the development and
dissemination of multi-hazard climate emergency preparedness and response plans for each county with an
emphasis on climate emergency preparedness and response plans that consider planning for climate shocks,
including annual flooding and high heat, coordinated with National and State level plans; and (g) trainings for
health facility, CHD, and State MoH staff on climate emergency preparedness and response as well as climate and
health adaptation.
34. Component 2: Health Systems Strengthening (WHO will implement; US$15.00 million: US$5.50 million
equivalent IDA [including US$3.72 million WHR] and US$9.50 million Trust Funds [US$1.0 million SDTF and
US$8.50 million MDTF]). This component is aligned with the MoH’s HSSP and will undertake activities to
strengthen South Sudan’s health system to facilitate health service access and capacity improvements, with an
emphasis on developing the stewardship capacity of the MoH, SMoHs, and CHDs. The component will be
implemented by WHO and will focus on strategic mechanisms to strengthen services in South Sudan, given the
low-infrastructure and conflict-affected context. Component 2 activities will be closely aligned with and
complementary to health service delivery activities under Component 1, through close coordination between
UNICEF and WHO with leadership from the MoH.
35. Subcomponent 2.1: Health Emergency Preparedness and Response, Laboratory Strengthening, and Disease
Control (WHO will implement; US$5.5 million: US$2.04 equivalent million IDA [including US$1.38 million WHR]
and US$3.46 million Trust Funds [US$0.36 million SDTF and US$3.10 million MDTF]). This subcomponent will
improve the health system’s ability to prepare for and respond to health emergencies and control diseases by
strengthening emergency preparedness, laboratory, and disease control systems. It will build on the work
conducted through the COVID-19 Emergency Response and Health System Preparedness Project (CERHSPP-
P176480) and needs identified in the National Action Plan for Health Security (NAPHS) 2020-2024. Specific
activities will include: (a) training and operational support for Integrated Disease Surveillance and Response
(IDSR); (b) operational and rehabilitation costs for three Public Health Emergency Operations Centers (PHEOCs);
(c) development, dissemination, and training of trainers on multiphaser emergency preparedness and response
plans, with an emphasis on climate shock emergency preparedness and response; (d) training and staff costs for
Point of Entry (PoE) surveillance; (e) update and disseminate laboratory guidelines; (f) procure laboratory
equipment, consumables, reagents, and test kits; (g) develop a national laboratory quality accreditation program
and scale up laboratory quality management; (h) Neglected Tropical Disease (NTD) program management training
and training of trainers for health service delivery, review of NTD indicators, and execution of community based
drug distributions; (i) development of noncommunicable diseases (NCD) guidelines and training of trainers for
NCD health service delivery; and (j) viral hepatitis, sexually transmitted disease (STD), and tuberculosis (TB) and
HIV training of trainers, diagnostic equipment procurement, and development and dissemination of guidelines.
36. Subcomponent 2.2: Blood Banking and Transfusion (WHO will implement; US$2.50 million: US$0.93 million
equivalent IDA [including US$0.64 million WHR] and US$1.57 million Trust Funds [US$0.17 million SDTF and
US$1.40 million MDTF]). This subcomponent will focus on strengthening the country’s blood banking and
transfusion system, which currently has very limited reach, impairing access to CEmONC and safe surgical services.
It will: (a) develop guidelines for the proper collection, storage, transport, and use of blood for transfusions; (b)
build or strengthen existing blood banking services; (c) develop systems and protocols for the transfer of blood
products for transfusion; (d) conduct community and donor sensitization on the collection and use of blood
products; and (e) develop low literacy visual tools and protocols for oral SBCC on the collection of blood products
to be used by health workers, emphasizing community-level communication activities.

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37. Subcomponent 2.3: Health Service Quality Improvement (implemented by WHO; US$2.5 million: US$0.83
million equivalent IDA [including US$0.53 million WHR] and US$1.67 million Trust Funds [US$0.17 million SDTF
and US$1.50 million MDTF]). This subcomponent focuses on improving health service quality in South Sudan by
addressing the challenges of remote health facilities, shortage of qualified health workers, and a long history of
low health service quality. This subcomponent will: (a) develop an HRH policy, strategy, and manual; (b) implement
the national Human Resources for Health Information System; (c) review and update the health worker training
curriculum; (d) review and update the essential medicines list and standard treatment guidelines, including
rational use of medicines; strengthen the capacity of the Drug and Food Control Authority (DFCA) at the State and
National levels through training, development of tools and guidelines, and operational support for testing and
supervision; (e) review and update the national quality of care policy and strategy; (f) review and update the
BPHNS; and (g) establish a quality of care system through development of guidelines, tools, and standards, training
of trainers on quality of care, piloting quality of care teams and supporting national scale up, and support for
National and State level quality improvement supervision.
38. Subcomponent 2.4: Health Management Information Systems (WHO; US$2.50 million: US$0.93 million
equivalent IDA [including US$0.63 million WHR] and US$1.57 million Trust Funds [US$0.17 million SDTF and
US$1.40 million MDTF]). This subcomponent will focus on developing systems and procedures for the national
HMIS, with an emphasis on supporting the collection of routine data through DHIS2, to standardize data collection,
entry and cleaning, as well as instituting data quality improvement practices. This will enhance targeting and data
tracking for refugees and provide regularly updated information to understand the evolving needs on the ground
that will aid further in the decision-making process. The subcomponent will: (a) finance procurement of
information communication technology equipment at the national level and train staff on data entry and use; (b)
train trainers to develop health facility staff data entry, management, and use capacity; (c) create interoperability
and integration between data systems and ensure data sharing, storage and backup; (d) develop, print, and
disseminate Standard Operating Procedures for HMIS data entry, cleaning, quality improvement, and use at all
levels; (e) conduct data review meetings and generate data use tools; (f) establish and operate the National and
State level HMIS and Monitoring and Evaluation (M&E) Technical Working Groups; (g) conduct data quality
improvement activities at the facility and national level; (h) operationalize a national and state level research
committee, building on existing structure; (i) conduct an annual health sector review meeting; and (j) maintain
and institutionalize the Health Service Functionality (HSF) Database.
39. Subcomponent 2.5: Health Sector Stewardship and Financing (WHO implemented; US$2.00 million: US$0.77
million equivalent IDA [including US$0.54 million WHR] and US$1.23 million Trust Funds [US$0.13 million SDTF
and US$1.10 million MDTF]). This subcomponent aims to enhance the health sector stewardship and financing
capacities of the national and state level MoHs. Core activities will include: (a) train national and state MoH
managers and leaders on leadership, management, policy formulation, operational planning, data use for decision
making, and budgeting; (b) develop annual operational plans at the national and state levels, aligned with the
MoH’s HSSP; (c) establish health sector coordination units at the national and state MoHs by setting up offices;
(d) conduct intersectoral and inter-ministerial advocacy on the determinants of health through the development
of materials and health communication activities; (e) develop a Public Private Partnership framework; (f) conduct
a National Health Accounts (NHA); (g) develop, validate, and disseminate a national Health Financing Strategy;
and (h) develop MoH capacity for FM, with a focus on improved budget execution, and intersectoral advocacy for
health sector budget allocations.
40. Component 3: Monitoring and Evaluation and Project Management (competitively selected third party
monitoring [TPM] agencies and the Project Management Unit [PMU] will implement; US$23.73 million:
US$10.79 million equivalent IDA [WHR] and US$12.94 million Trust Funds [US$1.36 million SDTF and US$11.58
million MDTF]). Component 3 will finance costs related to M&E and management of project activities. The project
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will ensure that independent and credible data on health service delivery and coverage and commodities are
generated and that the data are usable and used to enable the Government, the World Bank, and development
partners to verify that resources are reaching the intended beneficiaries and minimize potential harm. The
monitoring entities’ roles will include working with the PMU, UNICEF, the World Bank, and IPs to explain results,
providing guidance on improved methods, proposing context-appropriate solutions, and conducting ex-post fact
verification of results provided by project reporting mechanisms.
41. Subcomponent 3.1: Third Party Monitoring (Competitively selected TPM agencies; US$13.75 million: US$6.15
million equivalent IDA [WHR] and US$7.6 million Trust Funds [US$0.8 million SDTF and US$6.8 million MDTF]).
The project will finance TPM of delivery of basic health services under Subcomponent 1.1 and will build on
arrangements through the COVID-19 Emergency Response and Health System Preparedness Project (CERHSPP-
P176480), incorporating lessons learned from the project. TPM will provide critical assessment and survey data,
in complement to routine data through DHIS2, in support of the country’s overall HMIS. The TPM arrangements
will incorporate quarterly health facility functionality assessments and data quality verification; biannual health
service quality assessments, patient feedback, and BHI performance visits; and baseline and endline household
coverage and citizen engagement surveys. The TPM agent will be selected for the full project period through a
competitive process, with close attention to their capacity to scale up nationwide. To facilitate nationwide scale-
up, multiple agencies may be recruited with an anticipated geographic division of labor using standardized data
collection, entry, analysis, and reporting tools nationwide. TPM arrangements are outlined in detail in Annex 2.
Along with monitoring and survey activities, the TPM will develop Government capacity for the design of data
collection tools, data use, and oversight of health service monitoring.31
42. Subcomponent 3.2: Data Analysis and Visualization Platform (Competitively selected TPM Agency; US$0.73
million: US$0.30 million equivalent IDA [US$0.0 million IDA Grant and US$0.30 million WHR] and US$0.43
million Trust Funds [US$0.05 million SDTF and US$0.38 million MDTF]). To facilitate data sharing and use, the
subcomponent will develop a data visualization and use platform (software) focusing on visual representations of
TPM and routine data, inclusive of BHI data. Linking of platforms, including DHIS2 and the HSF platform will be
integral to the work. The data visualization platform will include visualization of Results Framework data and other
core indicators from the HSSP, linking TPM and DHIS2 data using maps, charts, and graphs and will incorporate
HSF data along with the overlay of health and meteorologic data to better understand the impact of climatic
patterns on health. The platform will include analysis of health service delivery in refugee and host community
areas to facilitate improved health service delivery among the critical underserved populations. The development
of an integrated, institutionalized, and sustainable platform which will strengthen MoH systems will be
emphasized. Annex 2 provides further details on the platform.
43. Subcomponent 3.3: Contract and Program Management Capacity Development (PMU; US$3.44 million: US$1.54
million equivalent IDA [WHR] and US$1.9 million Trust Funds [US$0.20 million SDTF and US$1.7 million MDTF]).
This subcomponent will develop the capacity of the PMU (through consultancy work) to manage health service
delivery contracts focusing on monitoring health service delivery performance and taking actions; resolve disputes
related to health service contracts; review and provide feedback on contractor deliverables; liaise and coordinate
with other relevant departments within the MoH to provide technical guidance to contractors; provide field-level
supervision to contractors; and develop a contract management manual. The subcomponent will also provide
capacity development support (training activities) for day-to-day and strategic program management of the PMU
along with capacity development for specific technical areas as needed. The capacity development support will

31
Geocoded technology will be used to track TPM data collection activities and facilitate near-real-time reporting of field data. All data will be
shared directly with the World Bank and PMU. The World Bank reserves the right to request changes to the TPM process, data collection tools, and
so on to ensure TPM is meeting project needs.

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include developing systems, processes, and tools, needed for effective functioning of the unit. This subcomponent
will finance: (a) technical assistance and capacity development on contract, environmental and social risk, and
program management; and (b) the development of the contract management manual. Specialized experts will be
recruited by the PMU to conduct capacity development activities.
44. Subcomponent 3.4: Project Management (PMU; US$5.81 million: US$2.80 million equivalent IDA [WHR] and
US$3.01 million Trust Funds [US$0.31 million SDTF and US$2.7 million MDTF]). This subcomponent will finance
the day-to-day operations of the PMU including project supervision, management, and oversight. The
subcomponent will support: (a) PMU staff costs; (b) PMU project supervision and oversight; (c) environmental and
social risk management activities; (d) PMU office equipment, stationary, and other day-to-day operating costs; €
State MoH project supervisory visits; (f) costs of specialists needed to support the project; and (g) operational
costs of the project’s Steering Committee.
45. Component 4: Contingent Emergency Response Component (CERC) (US$0). The objective of this component is
to facilitate access to rapid financing by allowing for reallocation of uncommitted project funds in the event of an
eligible emergency as defined in OP 8.00, such as a disease outbreak or health emergency with the potential to
cause a major adverse economic and/or social impact. Any WHR resources that become reallocated to the CERC
will only be used to benefit refugees and host communities. Disbursements under this component will be subject
to the declaration of emergency, a formal request from the Government, and the preparation of a CERC manual,
an ‘Emergency Action Plan’, and necessary environmental and social instrument(s) by the contracted
agencies/PMU, agreed upon by the World Bank. The Project Implementation Manual (PIM) will provide guidance
on the required documents and process for triggering the CERC.
Table 1: Project Cost and Source of Financing
Project component Source of Financing TOTAL
IDA MDTF SDTF Gov
Component 1: Provision of Basic Health Services Nationwide 100.71 196.92 23.14 10 330.77
Component 2: Health Systems Strengthening 5.5 8.5 1 0 15
Component 3: Monitoring and Evaluation and Project 10.79 11.58 1.36 0 23.73
Management
Component 4: Contingent Emergency Response Component 0 0 0 0 0
Total 117 217 25.5 369.5

C. Project Beneficiaries
46. The population of South Sudan, particularly women of reproductive age and children under five, will continue to
benefit from the sustained delivery of basic health services under the project. The project will cover all ten states
and three administrative areas of South Sudan with an estimated population of 12.4 million, 6.5 million of which
are female, and an estimated 2.9 million (23 percent of the total population) are of child-bearing age. About 2.4
million children are under five and make up 19 percent of the total population. Project beneficiaries will also
include about 330,000 refugees and their host communities. Furthermore, 67 percent of health facilities (1,158)
will benefit from the project, while the health system will be strengthened with support for essential system
elements, and health sector stewardship capabilities of the MoH at different levels will be strengthened.
D. Results Chain

47. Activities financed under the project will improve access to basic health and nutrition services to the population
of South Sudan including refugees and host communities, strengthen health systems, and lay the foundation for
building MoH capacities on project management and enhance M&E capacities. These activities will contribute to

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outputs such as the number of beneficiaries receiving basic package of health and nutrition services including
among refugees and host communities, the expansion of BHI, increased of number of health facilities that have
received pharmaceutical supplies ahead of the distribution period, functional laboratories, and enhanced health
sector coordination. In turn, these are expected to lead to the following outcomes: improved access to basic
package of health services, strengthened health systems, and improved government stewardship capacity. In the
long-term, the impact of the project will be improved health outcomes nationwide.
Figure 1. Theory of Change

roblem Statement: Limited access to health services , constrained government capacity, and a weak health system nega vely impact
health outcomes in South Sudan, which are further constrained in refugee and host communi es

c vi es utputs ntermediate utcomes igh level

Deliver a package o priori ed health and utcomes
nutri on services na onally with targeted Child and Maternal health services received by
bene ciaries na onally and in refugee host General service Expanded
delivery to re ugee and host communi es or Improved
improved access Services include maternal and communi es availability score a cces sto a
child health services, preventa ve and cura ve GBV Services received by bene ciaries na onally and in ba s i c pa cka ge hea l th
services, GBV services, at: (i) health facili es (ii) na onally and in refugee host communi es refugee host
of hea l th a nd outcomes
The community level through the Boma Health Percentage of women receiving at least four communi es na ona l l y a nd
Ini a ve antenatal care visits na onally and in refugee Increased of nutri on
rain health workers and supervise health host communi es s ervi ces to fa ci l i ta te
Bomas covered by
facili es na onally with targeted trainings to the BHI na onally
s ervi ce del i very
re ugee and host communi es to improve Health Workers trained na onally and in refugee and in refugee host i n refugee
service access host communi es hos t
Procure, deliver, and manage pharmaceu cals
communi es
Health Facili es supervised na onally and in
and medical supplies using climate sensi ve refugee host communi es
communi es .
planning with targeted delivery to refugee and Improved Improved:
host communi es for improved pharmaceu cal Pharmaceu cals in stock in health facili es Ma terna l
na onally and in refugee host communi es
Increased percentage hea l th s ector
access
of health sector s tewa rds hi p morta l i ty
Climate sensi ve health acility unc onality coordina on
and pharmaceu cal store improvements
Health facili es receiving climate friendly ra on
rehabilita on water and sanita on mee ngs held with Under ve
na onally with strategic selec on of refugee and
improvements na onally and in refugee host minutes, analyzed
host community facili es to improve service
communi es data reviewed, and
morta l i ty
access ra te
ac on item follow up
Strengthen the health system through: Propor on of alerts inves gated in hrs Rate of
i) Emergency preparedness and laboratory
inclusive of ac on
Percentage of SMoH CHDs with work plans items in refugee and chi l dren
capacity development aligned to the HSSP
ii) Developing the blood baking system host communi es under ve
Percentage of facili es repor ng stock out of
iii) Improving health service quality Increase in General who a re
tracer commodi es (medicines and laboratory
iv) Strengthening the health informa on service availability Strengthened
reagents) wa s ted
system score na onally and hea l th
v) Improving health sector stewardship in refugee host Fa ci l i ty
s ys tem
Health system strengthening will include communi es morta l i ty
assessment and strategic ac ons to address ra te
service bo lenecks for refugees and host
communi es

E. Rationale for Bank Involvement and Role of Partners

48. The value added of supporting the delivery of a basic package of health services through a World Bank
supported operation is high, given the World Bank’s ability to provide higher-level technical oversight and
facilitate coordination and communication between the partner agencies. In this regard, the value of providing
support through the proposed operation is greater than the sum of its parts. The proposed operation will result
in ensuring continuity and expansion in the provision of basic health services in a coordinated manner to cover
different population groups who often shift their location in an environment where conflict and uncertainty
remain underlying factors. It can bring together diverse actors from both the development and humanitarian
service delivery segments and use their comparative advantages to ensure that those with the greatest need
benefit equitably from the project’s interventions. The project also invests significantly in building capacities of
health service providers and managers at the operational level to contribute to a stronger and resilient health
system in the country.
49. The pressing resource needs in the sector combined with the harmonized funding cycles of the largest health
sector development donors and strengthened leadership in the MoH present a unique opportunity for the next
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stage in integrating health financing and harmonizing health service delivery nationwide in South Sudan, through
the IDA co-financing arrangements (standalone trust funds) to cover health service provision across the country,
which complements government resources. Pooling health sector resources through the IDA co-financed by donor
funds will: (a) improve efficient use of limited available resources by consolidating management and monitoring
mechanisms in the country; (b) reduce fragmentation and simplify the Government’s coordination with health
sector partners; (c) help transition towards better governance of the sector through strong accountability
mechanisms; (d) ensure a streamlined package of services is delivered in a consistent manner throughout the
country through unified planning, budgeting, and implementation processes; a€(e) allow for lessons learned
through current and previous health service delivery modalities, such as the need for robust management and
supervisory systems, strong monitoring, and consistent supply chain systems.
50. und pooling mechanism is also an opportunity to strengthen the Government’s role as a steward of the
health sector through a gradual shift toward Government contracting of health service providers. Health sector
stewardship, overseeing and regulating health services, is an essential role of the MoH. All other roles in the health
sector including service delivery, execution of monitoring functions, and pharmaceutical management could be
contracted out to third parties such as (international) NGOs, under the leadership and oversight of the MoH.
Currently, several implementing actors deliver health services, manage pharmaceuticals, and conduct monitoring,
with no substantive oversight or regulation from the MoH. Lessons from other fragile and conflict-affected
situations have shown that reaching a government-led management of health service delivery and service
contracting requires a gradual transition to strengthen the MoH’s stewardship functions while expanding health
service coverage and quality.
F. Lessons Learned and Reflected in the Project Design
51. The project is informed by over a decade of World Bank experience working in South Sudan, both in the health
sector, supporting two of the most conflict-prone states in the country, as well as service delivery in other sectors
in other states. The World Bank has been part of donor coordinated efforts to provide basic services in South
Sudan since the time of the Comprehensive Peace Agreement. The South Sudan Country Engagement Note (CEN
-FY21—23) provides several key lessons from across the portfolio which have been considered in designing–the
project. First, there is recognition that, to ensure any significant impact on service delivery, there is a need for
flexibility both at the strategic and operational level to increase speed in delivery of services, accountability and
citizen engagement, and strategic partnerships given the enormity of the needs, the scope, and limited resources.
52. Fragile and complex environments require flexibility in project design and alignment to the political economy.
This ensures that the project activities and implementation plan can adapt to the volatile and constantly changing
environment of the country—whether economic or political. Building consensus and ensuring cohesion between
the Government’s priorities and the project’s components becomes critical in this context. Currently, South Sudan
is bound by the Revitalized Agreement on the Resolution of the Conflict in South Sudan (R-ARCSS) and is
implementing a road map agreement that will ensure elections are conducted in 2024. Such factors may have a
direct impact on the implementation of the project and therefore tailored yet adaptable interventions are
preferable.
53. Limited institutional capacity calls for simpler project design that have specific yet achievable results. Given the
MoH’s limited capacity, the core activities have been designed to focus on immediate priorities of the MoH which
can form the foundation for longer-term objectives. Furthermore, it is important to design realistic and achievable
PDOs in such environments. The World Bank will work closely with the MoH and provide the necessary advice and
capacity building at each stage of the project.

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III. IMPLEMENTATION ARRANGEMENTS

A. Institutional and Implementation Arrangements

54. The World Bank will set up a standalone MDTF and an SDTF. Donor grant financing will be pooled to co-finance
the IDA grant using the IPF instrument. The World Bank will manage the program (IDA and trust funds) through
its operational policies, procedures, and environmental and social risk management.
55. The timing and use of funds from donors will be governed by Administration Agreements between the World
Bank and the donors. The project will be submitted for approval with the IDA grant, and the amounts indicated
by the donor partners. The amounts received from donors after the signing of each respective Administration
Agreement will feed directly into the MDTF or SDTF pool of funds and will not require the processing of any
additional financing.
56. The project is a platform for donors to join, with a total cost of US$369.50 million, of which US$242.50 million is
expected to be co-financed by donor contributions between January 2024 and September 2024 (US$217 million
from the South Sudan Health Sector Transformation Multi-donor trust fund [MDTF] and US$25.5 million from a
Single-donor trust fund [SDTF]). The expected donors (Canada, EU, FCDO, GAVI, Global Fund, Sweden, and USAID)
have been an integral part of the discussion and preparation of the project. In case of any deficit, after
consultations with the Government, a project restructuring will be undertaken to downscale the scope of activities
and their respective targets. Similarly, any new additional donor interested in joining the co-financing mechanism
through pooling resources in the MDTF will sign an Administration Agreement and will be allowed to join after
receiving the World Bank’s and the MOH’s no objections. This is facilitated by the incremental nature of activities
under the design of the project. Several other donors have expressed their intent to join the program once it has
been approved (Annex 5).
57. The MoH will contract UNICEF and WHO as implementation partners. UNICEF will sub-contract NGOs to deliver
the identified package of health services and will provide robust, day-to-day supervision of the NGOs. UNICEF
will be in place to maintain service delivery if conflict resumes/intensifies in the country. The sub-contracted NGOs
will deliver the identified package of health services nationwide according to the required standards. WHO will
implement health system strengthening activities to facilitate health service access and capacity improvements at
national and state level.
58. TPM agency/ies will be contracted by the PMU, with World Bank oversight. TPM agencies will conduct household
and health facility surveys along with surveys to solicit community and patient feedback. TPM agencies will submit
quarterly monitoring reports to the PMU/World Bank.
59. Flow of funds. The funds for the project interventions and procurement of supplies will flow directly from the
World Bank to UNICEF, WHO, and the TPM agency/ies while the fund required for PMU salaries and operating
expenses will flow from the World Bank to the project designated account managed by the Government.
60. A PMU will be established at the MoH to manage health service contracting and the day-to-day engagement with
the Government, management organization, and donors. This PMU will include qualified and capacitated
government and non-government staff covering the skill mix required including project management, FM,
procurement and contract management, M&E and environmental and social risk management. The PMU will be
contracted by the MoH and report directly to the Undersecretary and will establish clear coordination mechanisms
with the relevant departments at the national and state Ministries of Health. The PMU will be responsible for
managing health service contracts, supervising project implementation, monitoring progress on results, and
submitting quarterly interim financial and progress reports as per the World Bank templates. The PMU will have

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a progressive role in project management based on the capacity acquired. In addition, the PMU will contract, with
World Bank guidance, technical assistance for capacity-building activities based on a needs’ assessment. The
current COVID-19 Emergency Response and Health System Preparedness Project (CERHSPP-P176480) is financing
customized institutional capacity development at the MoH; a PMU of 15 qualified members is in place at the MoH
and started engaging in oversight of core aspects of project activities. A new PMU will be established through an
open and competitive recruitment process to be carried out by the MoH with close support from the World Bank.
The current PMU team will provide good candidates for the new PMU. A PIM will be prepared, describing the
main activities to be carried out by the PMU and implementation modalities.
61. Two steering committees will be established. A High-level Steering Committee (HSC) will provide strategic
direction, overall coordination and policy guidance on the sectoral challenges and future steps on service delivery,
health financing, HRH, information system and medicines and supplies. The HSC will meet on a bi-annual basis. An
Operational Steering Committee (OSC) will provide routine oversight and technical guidance during project
implementation. The OSC will be responsible for ensuring that the implementation of the project is carried out
efficiently and with the necessary technical quality. The OSC will meet on a quarterly basis. The PMU will serve as
the Secretariat to the SCs and will organize meetings of the SCs based on directions received from the chairs. See
Annex 1 for membership and other details.
62. Consultation for activities in refugee hosting areas. The project will coordinate and seek to partner with UNHCR,
to (a) benefit from UNHCR’s expertise as the lead UN agency working on refugee issues; (b) capitalize on UNHCR’s
existing citizen engagement platforms to ensure the target groups are heard; and (c) identify ways to complement
ongoing health activities that UNHCR and its partners are implementing in these areas. In view of their lead role
on refugee protection, the project will also closely coordinate with CRA officials in refugee-hosting areas to ensure
refugees are equitably included in WHR-financed activities, as well as seek to foster collaboration between local
government health officials and CRA on this effort. Further, the OSC will liaise and frequently meet with the South
Sudan Humanitarian Cluster, a forum that involves all humanitarian players in the country.
B. Results Monitoring and Evaluation Arrangements
63. Monitoring and tracking of project outputs will rely on different sources of information and monitoring
mechanisms. Through its team and network of partners, implementing agencies will track the planned and actual
activities. An additional level of tracking will be through a TPM arrangement. Additionally, to significantly enhance
the transparency and accountability of TPM activities, the project will integrate support from the Geo-enabling
Initiative for Monitoring and Supervision (GEMS) to enhance the monitoring and supervision capacity of the
project. Working with GEMS will enable the World Bank to ‘monitor-the-monitors’ and get access to direct field
data in near real-time, rather than solely receiving aggregated periodic reports. Through the use of GEMS, the
project will seek to further build the local capacity to use technologies to collect and analyze data on the ground
to improve accountability for TPM and enhance transparency and accuracy of M&E activities.
64. The Results Framework for the project will build on the lessons from the COVID-19 Emergency Response and
Health System Preparedness Project (CERHSPP-P176480) and will aim at measuring actual service delivery
outcomes. UNICEF and WHO will provide detailed technical reports biannually with narrative updates on the
overall project implementation and results as well as reporting on the project’s Results Framework indicators. In
addition, quarterly matrices will be provided which will contain updated progress of Results Framework indicators
as well as social and environmental risk management.
65. The project will identify refugees and host communities’ beneficiaries by building on a targeting mechanism that
has been designed under the ongoing COVID-19 Emergency Response and Health System Preparedness Project
(CERHSPP-P176480) which uses a combination of geographic targeting and community-based targeting, with

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some filters mainly related to the presence of children below 12 years and pregnant women. The project will rely
on the refugee household data collected by UNHCR. The targeting methodology will be tested to ensure its
applicability to refugees and adapted as needed. Moreover, these activities will be complemented by a strong
communications campaign designed in partnership with humanitarian agencies to ensure that the project is seen
as fair to both refugees and host communities.
C. Sustainability
66. The project contributes to sustainability in two ways. First, in line with the CEN, the project focuses on building
the institutional capacity, enhancing stewardship and governance of the MoH. This will be undertaken through
customized training approach to MoH personnel to ensure an acceptable level of project management and
fiduciary oversight at the MoH before transitioning fully to a government-led implementation modality.
Investment under the project is expected to strengthen the health system in the country, ensuring institutional
sustainability to manage service delivery. By the end of the project, MOH will be able to: (a) monitor and evaluate
health programs; (b) lead the health sector planning and policy dialogue; (c) develop some public procurement
and public financial management capacity; and (d) manage needed environmental and social activities. Second,
the project will support the community-based approach through its community health services provided by BHWs.
Evidence indicates that community health workers continue to provide some services such as health promotion
and awareness even when funding stops. Furthermore, all project activities are aligned with the Government’s
priorities detailed in HSSP 2023—2027 and therefore their commitment will help drive the initiatives as well as
sustain gains supported by the project.

IV. PROJECT APPRAISAL SUMMARY

A. Technical, Economic Analysis

Economic analysis

67. The economic benefits of investing in health and nutrition services are high. The number of children below 11
years represents more than 40 percent of the population in South Sudan. The identified package of nutrition
services under the project will follow a life cycle approach and will focus on children, women of reproductive
age, and pregnant and lactating women. Those evidence-based services have been proven to yield high benefit-
cost ratios. Investing in specific children and maternal nutrition interventions have been estimated to yield
between US$11 and US$35 for each US$1 invested. Not only are investments in nutrition one of the best value-
for-money development actions, but they also lay the groundwork for the success of investments in other
sectors. Therefore, the US$25 million which will be invested in nutrition under the project is expected to yield
between US$275 million to US$875 million worth of benefits and returns, especially to the refugee and host
communities where most of the support is allocated.
68. South Sudan registers one of the World’s highest maternal mortalities (1,150 deaths per 100,000) and under five
mortality (100 per 1,000 live births). Assuming that the project will help a conservative reduction in maternal
mortality by 10 percent over the project duration, this will save around 27,920 under five lives of which 2,700
children in refugees and host communities and 51 women’s lives of which 172 are in refugees and host
communities population. Applying a conservative statistical value of life for low-income countries (US$41,756),
this will yield an approximate US$1.187 billion in benefits, of which 120 million are direct benefits to the refugees
and host communities.

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Paris Alignment
69. The project is fully aligned with the adaptation and mitigation goals of the Paris Agreement on Climate Change.
The project supports integrated investments to ensure that health service delivery and systems strengthening
activities minimize the risk of climate shocks to activities and greenhouse gas emissions from activities. The
publicly disclosed climate change technical note presents a comprehensive outline of climate activities in the
project.
70. Adaptation goal and risk reduction measures. The main risks to project activities are flooding and high heat. Both
are anticipated annually based on seasonal weather patterns and a lack of adaptive capacity in the country, with
the potential for extremely high health and extreme flooding during the project period. To address the risks of
climate to health service delivery under Subcomponents 1.1 and 1.2, Subcomponent 1.4 will include the
development of county-level multi-hazard emergency preparedness and response plans with an emphasis on
climate emergency preparedness and response for health service delivery and training for staff on these plans.
These plans will detail preparatory and response activities to reduce the risk of climate shocks on activities. In
addition, health service delivery through the BHI under Subcomponent 1.2 aims to ensure consistent delivery of
health services during flooding, with detailed plans to be reinforced in the climate emergency preparedness and
response plans. Subcomponent 1.3 will include climate-sensitive planning, with annual dry season prepositioning
plans developed and executed to ensure pharmaceuticals are in place and securely stored ahead of the rainy
season. Subcomponent 1.4 will include climate-adaptive pharmaceutical store rehabilitation to ensure adequate,
secure pharmaceutical storage capacity for pharmaceutical prepositioning and storage. The subcomponent will
also include water and sanitation improvements to health facilities to reduce the risk of vector-borne and
waterborne climate-sensitive diseases at health facilities. Minor rehabilitation of pharmaceutical stores and health
facilities will focus on climate adaptation measures to reduce heat and flood exposure. A specialized consultant
will be hired to incorporate climate adaptation measures into health facility and pharmaceutical store
rehabilitation. Subcomponent 2.1 will include national and state level multi-hazard climate emergency
preparedness and response plans with an emphasis on climate change emergency preparedness and response,
with which county-level plans will be aligned, to minimize the risk of climate shocks to health systems
strengthening and PMU activities.
71. Mitigation goal and risk reduction measures. Most activities in the project are on the universally aligned list for
climate change mitigation. Minor rehabilitation activities under Subcomponent 1.4 will ensure at least 20 percent
more energy efficiency than standard practice, aligning with EDGE level 1 building criteria. An energy efficiency
consultant will be hired to conduct an energy efficiency audit and ensure these measures are incorporated into
health service delivery. Subcomponent 1.4 will also finance solar power for sustainable health facility
electrification.
Technical
72. The proposed HSTP will strengthen MoH capacity in management of health services and will contribute to the
sustainability of the program. The project has been specifically designed to ensure that the South Sudanese
population continue to have access to critical health care services. To guide the design of the operation, several
key principles were used in formulating the project activities:
(a) Achieve a balanced approach on two fronts: (i) providing a package of basic health and nutrition services
based on the principle of continuum of care throughout the lifecycle (childhood, adolescence/adulthood,
pregnancy, childbirth, postnatal period), and among the models of service delivery (including clinical care settings,
outreach, and household and communities); and (ii) supporting the primary care facilities nationwide with the
basic inputs for maintaining their operational capacity.

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(b) Support the delivery of an integrated package of services building on the experience of the ongoing IDA
funded health operations. There are predefined guidelines and protocols for integrated service delivery and
facility-based health planning suited to South Sudan that are consistent with the current capacities in the country.
These standards ensure that (i) delivery through facilities is focused on basic health and nutrition services and
ensure optimum use of the limited resources, (ii) routine outreach and community-based services are planned to
complement delivery through fixed services, and (iii) mobile teams respond to the needs of disadvantaged groups
in areas lacking functional fixed facility or refugees and host community areas.
B. Fiduciary
(i) Financial Management
73. An FM assessment was carried out covering planning and budgeting, accounting, internal control including
internal audit, financial reporting, funds flow, and external audit arrangements.
74. The objective of the FM assessment was to determine whether the MoH maintains adequate FM arrangements
to ensure that: (a) project funds channeled through the MoH will be used for the purposes intended in an efficient
and economical manner; (b) the project’s financial reports will be prepared in an accurate, reliable, and timely
manner; and (c) the project’s assets will be safeguarded from loss, abuse, or damage.
75. The assessment indicates that basic FM systems and capacity exist in the MoH, but the overall status is considered
weak. There are significant capacity gaps within the MoH, which could materially affect the implementation of
the HSTP if not mitigated. These include weak and inadequate budgetary preparation and monitoring systems,
weak capacity, lack of budget monitoring tools, inadequate staffing capacity, and weak manual accounting system.
Weaknesses in the internal control systems include deficiencies in payment authorizations, lack of documented
policies and procedure manuals, inadequate segregation of duties with some overlapping roles, and lack of a
functional internal audit unit. The external audit also identified weaknesses on the project previously
implemented by the ministry, some of which remain unresolved including lack of bank reconciliation statements,
no internal audit, and computerized accounting system acquired for the project not used and not available as of
the assessment date. As a mitigation measure, the FM arrangements for the project will be discharged through a
PMU to be set up within the ministry. The FM activities at the PMU will be overseen by a FM specialist, supported
by a project accountant hired for the project and complemented by finance staff deployed by the MoH to
strengthen capacity within the ministry. There will also be hands on support and close monitoring by the World
Bank. Based on the findings, the overall residual FM risk rating will be substantial.
(ii) Procurement
76. Procurement capacity assessments of the MoH. The MoH will implement the project through the PMU to be
established at the national level. A procurement capacity risk assessment was conducted as part of project
preparation, and general findings from the country situation. The MoH, like many MDAs, does not have a
functional procurement unit. Procurement processes are carried out as administrative functions and though the
procurement department exist and is headed by the deputy director, there are no dedicated procurement staff.
The PPDA Act 2018 provides for establishment of Procurement Unit and Procurement Committee at each
procuring entity, and all procurement functions are to be carried and managed by the Procurement Unit. It was
established that though the MoH has had experience implementing World Bank-financed projects, the staff being
recommended to the PMU have no direct experience with the World Bank’s Procurement Regulations.
77. Project Procurement Strategy for Development (PPSD) and Procurement Plan. A PPSD was developed to improve
implementation of the project and help achieve results. The Government has prepared the Procurement Plan for
the initial 18 months, setting forth the selection methods to be followed by the implementing entities during
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project implementation in the procurement of goods, works, and non-consulting and consulting services financed
by the World Bank. The Procurement Plan will be updated at least annually or as required to reflect the actual
project implementation needs and improvements in institutional capacity. Over 80 percent of the project activities
will be implemented through an Output Agreement (UNICEF and WHO). UNICEF and WHO shall be contracted to
implement through Output Agreement Component 1 (UNICEF) and Component 2 (WHO). All procurement of
medical commodities will be handled by UNICEF and WHO based on their systems. The PMU will provide
coordination and management roles of the project and supported by TPM agency/ies to be hired by the project.
78. Through an MoH request, the World Bank will approve a Hands-On Extended Implementation Support (HEIS)
consultant for a 6-12 months’ period to support the establishment of the PMU through advancing the recruitment
of key consultants and initiating the contracting of UNICEF and WHO. The hiring of UNICEF and WHO will be done
through Systematic Tracking of Exchanges in Procurement (STEP) and the World Bank’s no objection will be
required prior to the finalization and signing of the agreement. To enable transfer of knowledge, the MoH will
second a procurement officer to work with the procurement consultant hired at the PMU.
79. The Procurement risk for the project is rated as ‘High’. There is an incomplete public procurement framework,
lack of a functional Procurement Unit and oversight functions at the MoH, and general weak public financial
management governance. The World Bank’s experience and assessment of key issues and risks concerning project
procurement processes in South Sudan has also shown several challenges which include: (a) lack of commitment
from the Government officials / civil servants in implementation of the project due to irregular and low
remunerations (b) delayed procurement and contract implementation due to inadequate number of technical
staff to handle increased volume of procurement and contract administration; (c) weaknesses in procurement
planning resulting in inappropriate packaging of contracts, high prices and delayed implementation of the project;
and (d) weak procurement oversight and contract management resulting in delayed implementation and
potential loss of value. The mitigations measures include the following: establishment of the PMU staffed with
experienced procurement and other expert consultants, World Bank providing HEIS to support the establishment
of PMU and contracting of UNICEF and WHO; and advance procurement of major activities to fast-track
implementation of project, including preparation of Procurement Manual and hiring of a procurement specialist
as an effectiveness condition, among other conditions.
C. Legal Operational Policies

@#&OPS~Doctype~OPS^dynamics@padlegalpolicy#doctemplate
Legal Operational Policies Triggered?
Projects on International Waterways OP 7.50 No
Projects in Disputed Area OP 7.60 Yes

80. The Bank’s Policy on Projects in Disputed Areas (OP BP 7.60) applies to the South Sudan HSTP because of
territorial dispute between South Sudan and Sudan, Uganda, and Kenya. Some parts covered by the project fall
within the general areas under dispute. In line with OP 7.60, the Bank has ensured compliance with the
requirements of the policy and notified the project to the authorities of Sudan, Uganda and Kenya. Given that the
World Bank considers that the execution of the project is not prejudicial to the interests of these countries and
that the World Bank does not intend to pass any judgment with regard to the legal status, nor any other status in
reference to the territories concerned and does not intend to prejudge or influence the final decision of the

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International Court of Justice regarding the claims of South Sudan, Sudan, Uganda and Kenya, no objection to the
project has been raised.
D. Environmental and Social
81. The project’s overall environmental and social (ES) risk classification is rated high. Nine of the ten ESS (except ESS
9) of the World Bank Environmental and Social Framework are relevant to the project. Description of the
environmental, social, health, and safety risks and impacts related to the project and the proportionate mitigation
measures is summarized as follows.
82. Environmental risks. The nationwide provision of basic health services of Component 1 poses several
environmental, health, and safety (EHS) risks. The procurement and distribution of essential drugs and medical
supplies could result in waste generation if not managed properly, leading to environmental contamination. The
increased outreach and use of mobile health services may also lead to higher fuel consumption and vehicle
emissions, contributing to air pollution. Also, to improve access to remote communities, existing/new facilities or
infrastructure might be rehabilitated/constructed, which could cause deforestation of natural and/or critical
habitats. The rise in health services delivery may also lead to a higher amount of medical waste. Component 2 will
focus on strengthening South Sudan’s health system to facilitate health service access and capacity improvements,
including development/updating of policies and legal frameworks which may have direct/indirect EHS risks to people
and the environment. It will also support laboratory strengthening, disease control, and procurement and use of ICT
equipment which could require waste management. Also, the use of certain chemicals and biological agents for
disease control and prevention during emergency preparations could pose environmental hazards if not managed
and disposed of properly, whereas, under Component 3, developing and maintaining a common monitoring
mechanism and databases may require significant energy and data storage resources, contributing to higher carbon
footprints and e-waste generation. Finally, the need for rapid infrastructure construction and the distribution of
relief supplies during emergency response efforts of CERC may entail resource-intensive activities that have
environmental consequences. There are also potential occupational health and safety and community health and
safety risks associated with all components of the project.
83. Social risks: The project social risks are classified as High. The project could face multiple potential social risks as it
will be implemented nationwide where prevalence of poverty, drought, security challenges, and many more
complex social issues under the FCV context of South Sudan are severe. Investments and support to service
providers, including in the health sector, increases the risks of service providers becoming targets of attacks,
pillaging, and acts of violence by armed groups. Cases of health facilities and hospitals being raided have been
documented in South Sudan and experienced during implementation of the parent and previous health projects.
These include risks resulting from (a) inter/intra-communal tensions, including between refugees and host
communities, over implementation issues, (b) assets and staff becoming targets of violent groups, and (c) GBV and
SEA/SH risks that are prevalent and heightened in conflict-affected areas. The SEA/SH risk of the project is
considered High. Pervasive incidences of GBV in South Sudan are a significant contextual challenge, exacerbated by
a context of pervasive insecurity in the country. More specifically, Component 1 includes activities which may
potentially exacerbate existing inequalities or cause social exclusions in health service access, especially for
vulnerable and conflict-affected communities. The project activities including the technical assistance activities
involve limited potential social risks associated with labor, labor conditions, safety and security of project workers,
exclusion of beneficiaries during targeting, and delivery of capacity development trainings, compromising the service
delivery quality, and challenges of ensuring the quality and reliability of the data generated, particularly in areas
with limited human resources and infrastructure.

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84. Risk Management E&S instruments: To effectively assess, manage and monitor the potential the environmental,
social, health and safety risks, the project developed the following ESF instruments: Environmental and Social
Commitment Plan (ESCP) and Stakeholder Engagement Plan (SEP), and disclosed them on November 24,2023 on
Ministry of Finance and Planning website; Environmental and Social Management Framework (including Labor
Management Procedures, and GBV/SEA/SH Risk Assessment and Action Plan, General Medical Waste Management
Plan, and Social Assessment with Social Development Plan); Resettlement Framework; and Security Risk Assessment
and Management Plan as conditions of effectiveness as the project is being processed under the World Bank Policy
for IPF, paragraph 12.
85. Gender. Women and girls in South Sudan face considerable socio-economic and cultural challenges that contribute
to gender gaps in health outcomes and health services. South Sudan has the highest maternal mortality in the world.
The fertility rate is also high. The project document identifies early marriages and high fertility, poor access to
essential healthcare, and high risk of experiencing SGBV as key issues that affect women and girls’ sexual and
reproductive health. These outcomes are the reflective of a lack of women’s empowerment and their poor access
to essential healthcare. Cultural beliefs and fertility preferences contribute to the cycle of early marriages and high
and early fertility on the one hand, and on the other demand side challenges such as limited awareness of the
benefits for reproductive and maternal healthcare, hidden cost of services, opportunity cost of time, and security
concerns deter women from seeking health services. On the supply side, a weak health system with limited
infrastructure and disrupted access to health and nutrition services due to emergency situations such as floods make
it difficult to ensure that pregnant women and adolescent girls receive appropriate care. Improving women and girls’
use of reproductive maternal health will contribute to reducing maternal mortality. This requires improving the
access to and the availability of sexual, reproductive, and maternal health services, especially at the community level
which includes family planning information, and education, communication (IEC)/social and behavior change
communication (SBCC) to reduce misconceptions about sexual and reproductive healthcare and promote delayed
births and birth spacing, which are critical for bringing down maternal mortality, especially among younger,
adolescent girls.
86. SGBV is also of concern in South Sudan. However, the response to SGBV in the country remains inadequate. There
is limited capacity within the health system provide appropriate care to survivors of SGBV. Moreover, the stigma
associated with rape and sexual violence continues to be a barrier for women and girls in acknowledging the
experience and seeking timely and appropriate healthcare for SGBV. There is a need for strengthening the
availability of trained medical personnel who can handle Clinical Management of Rape (CMR) and provide basic
psycho-social support in a safe environment.
87. Proposed actions under the project. Component 1 of the project supports delivery of a set of prioritized services
that cover sexual, reproductive, and maternal health and nutrition services that include family planning counselling
and delivery of family planning services, ANC, skilled attendance at birth, basic and comprehensive EmONC, and
PNC. This comprehensive package of services is essential to ensure that pregnant women, girls, and their newborns
have the best chance of surviving birth, especially when there are complications. It is also important for providing
the means to exercise more agency in determining the size of families and timing of births – again important for
reducing maternal mortality. In addition to strengthening service delivery at primary secondary and tertiary facilities,
the component will support the hiring and training of Boma Health Workers (BHWs), including female BHWs, to
reach vulnerable and hard-to-reach groups at the community level and last mile delivery of medical supplies and
pharmaceuticals. This is especially important for reaching women, mothers, and their children in rural and remote
areas. The component will also support provision of SGBV care including identification, counselling, management
and proper referral for survivors of SGBV, including rape victims. The intervention package includes BCC focusing
SGBV awareness and prevention. These three interventions (i) strengthening delivery of reproductive and maternal
health services, (ii) training and deployment of Boma Health Workers, especially female service providers, and (iii)
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provision of SGBV services, support the two broad issues identified in the PAD that disproportionately affect women:
(a) high fertility and maternal mortality, and (b) limited support for SGBV survivors. The following indicators will be
used to monitor progress on both these issues: (i) maternal mortality ratio; (ii) percentage of women receiving four
ANC visits; (iii) percentage of deliveries attended by skilled health personnel; (iv) contraceptive prevalence rate (any
method); and (v) number of Gender-Based Violence Services provided.
88. Citizen Engagement. The project will prioritize meaningful engagement of all direct and indirect stakeholders in the
health sector. This will be done through widescale consultative process with Government officials and will engage
all relevant donors and development partners and various sector experts/specialists. In addition, the M&E system
of the project will facilitate strong citizen engagement and beneficiary feedback throughout project implementation.
The project will ensure proactive feedback processes including a feedback mechanism for all health services
provided and trainings conducted by the project. Planned procurement activities will include hiring of two TPM
entities to verify that resources are reaching the intended beneficiaries and potential harm is minimized, consultancy
for health service quality assessment, and citizen engagement and beneficiary feedback surveys. The project will
implement and expand an existing GRM developed and implemented under the COVID-19 Emergency Response and
Health Systems Preparedness Project (CERHSSP-P176480) which aligns with the requirements of ESS 10 and other
relevant E&S standards. The proposed GRM is expected to provide an inclusive, accessible and safe GRM process
and procedures that receives and resolves grievances, closes the feedback loop with communities and builds trust,
sensitively handles corruption and SEA allegations, and provides the project with actionable data through which to
adjust and improve its programming.

V. GRIEVANCE REDRESS SERVICES

89. Grievance Redress. Communities and individuals who believe that they are adversely affected by a project
supported by the World Bank may submit complaints to existing project-level grievance mechanisms or the Bank’s
Grievance Redress Service (GRS). The GRS ensures that complaints received are promptly reviewed in order to
address project-related concerns. Project affected communities and individuals may submit their complaint to the
Bank’s independent Accountability Mechanism (AM). The AM houses the Inspection Panel, which determines
whether harm occurred, or could occur, as a result of Bank non-compliance with its policies and procedures, and
the Dispute Resolution Service, which provides communities and borrowers with the opportunity to address
complaints through dispute resolution. Complaints may be submitted to the AM at any time after concerns have
been brought directly to the attention of Bank Management and after Management has been given an opportunity
to respond. For information on how to submit complaints to the Bank’s Grievance Redress Service (GRS), visit
http://www.worldbank.org/GRS. For information on how to submit complaints to the Bank’s Accountability
Mechanism, visit https://accountability.worldbank.org.

VI. KEY RISKS

90. The overall risk to achieving the project objective is High. There are significant risks to implementing a project in
South Sudan, as evidenced from the previous and ongoing World Bank supported projects. The project will support
health services delivery in one of the most challenging FCV contexts in the world. This results in greater risks than
those found in non-FCV environments. More specifically, the acuteness of the violence and instability in the country
sets South Sudan apart from other FCV environments with even greater levels of risk.
91. Political and governance risks is High. The highly fragile context and political economy dynamics pose risks. The
country’s security situation remains volatile and intercommunal conflicts persist, which fuels further political

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uncertainty. There is also a significant risk that frequent changes in political leadership and appointees may
undermine government ownership and cause project delays. To mitigate this risk, the World Bank will continue to
engage at multiple levels within the MoH and MoFP and with key health sector stakeholders to ensure broad buy-
in and ownership. The project will also support regular coordination meetings and ensure flexibility so that
adjustments can be made during implementation. Political risks related to refugee issues are minimal, as the
Government and South Sudanese have adopted–in policy and practice–a progressive policy towards refugees.
92. Macroeconomic risks are High. South Sudan has one of the least diversified economies in the world, a result of
being extremely oil dependent. This has made the sector mainly depending on the donor funding with irregular
payment of salaries to civil servants including health workers. Even though inflation has seen a dramatic reduction
since the implementation of the Government’s reform program, the current commodity price shock and the
depreciation of the South Sudanese pound are expected to drive a rise in inflation in the short term.32 Despite the
depreciation of the South Sudan Pound, the premium between the parallel and official exchange rate remained low
at below 3 percent owing to the tight monetary policy stance, continued foreign exchange auctioning in a weekly
basis, and tightening of regulatory framework by the Central Bank. However, given the low gross reserve levels, the
likelihood of foreign exchange shortage is eminent, which, in turn, may result in parallel market distortions. The
Government’s commitment to contribute to the financing of health service delivery remains uncertain and may not
be fully adhered to. The proposed project will mitigate this risk by enhancing stewardship of the MoH and MoFP
and will develop a clear roadmap for the gradual handover of identified facilities to the Government to sustain.
Those facilities will be carefully selected at the beginning to avoid significant gaps in service delivery in case of
government’s non-adherence to their financial commitments.
93. Sector strategies and policies risks are Substantial. It is critical to recognize that after over five decades of
continuous assistance and presence in South Sudan, international actors and the aid they provide are now an
integral part of the local political economy. The continued change in the MoH leadership over the last few years
continued to disrupt the development of sectoral strategies. The provision of basic health services, however, is a
priority for the ministry. Maintaining a strong focus on procurement of necessary supplies and equipment and
training of health and non-health workers at targeted areas are key mitigation measures.
94. Technical design of the project risk is High. The targeting of refugees and host communities increases the
complexity of delivering health services. Experiences from humanitarian organizations provide valuable lessons
about how to ensure neutrality and impartiality in the delivery of these services. Various mechanisms are proposed,
both within agreements with the implementation agencies and across project components. In addition, robust
mechanisms for results monitoring and verification will provide an additional oversight in ensuring that the package
of services has reached the intended targeted populations of refugees and host communities.
95. Institutional capacity for implementation and sustainability risks are High. The risk of the MOH and PMU managing
service delivery at a national level is high and is currently being mitigated through an intensified capacity building
program on effective project management for several candidates. In addition, UNICEF will be subcontracted by the
PMU to provide service delivery activities of the project while WHO will provide the system strengthening elements.
Both agencies will seek to expand its operational and technical presence on the ground and nationwide to ensure a
smooth transition from World Bank/HPF and effective management of the new pooled fund program. It is expected
that by the end of the project MOH will have an enhanced capacity that will enable it to lead on some areas of
activity implementation in the future.

32
IMF Country Report No. 22/266, 2022 Article IV Consultation and Second Review under the Staff-Monitored Program, July 2022.
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South Sudan Health Sector Transformation Project (HSTP) (P181385)

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

97. Environmental and social risks are High. Despite the promising social impacts, the project social and SEA/SH risks
are classified as high. The project could face multiple potential social risks as it will be implemented nationwide
where prevalence of poverty, drought, security challenges, and many more complex social issues under the FCV
context of South Sudan are severe. The conflict has had a significant impact on children, with profound human rights
abuses conducted on them. In this context, investments, and support to service providers in the health sector
increases the risks of providers becoming targets of attacks, pillaging and violence by armed groups. Recent attacks
on health workers, within and outside the Provision of Basic Health Services Project, have highlighted that risk.
Evidence reveals that the context of pervasive insecurity in the country has heightened the risks associated with
GBV or SEA SH. The project’s environmental risk rating is Substantial due to EHS issues associated with (a) provision,
transport, storage, use and disposal of medicines and vaccines; (b) medical waste management; (c) worker and
community health and safety; and d) rehabilitation/construction of public health facilities. With the involvement of
the MoH as a direct implementing entity, its limited experiences of managing the environmental and social risks
would be concerning to effectively address the complex social issues, pervasive GBV incidents, substantial
environmental risks and potential grievances from project affected persons and other stakeholders. In sum, to
effectively assess, manage and monitor the potential environmental and social risks and impacts, the project will
develop proportional ESF instruments as stated in Section D.
98. Stakeholders’ risk is igh. Experiences from humanitarian organizations provide valuable lessons about how to
ensure neutrality and impartiality in the delivery of health services. Despite these lessons and the fact that partner
agencies are non-state actors, the proposed project will be implemented by the MOH/PMU, which carries additional
complexity in addressing issues to cover entire target populations and ensuring independence in service delivery.
To minimize the risks related to delivering goods to health facilities, communication and outreach activities will be
conducted to inform the public of the project’s support and increase visibility. In addition, the project will strictly
follow an objective methodology for procurement and distribution of required supplies to the target facilities.
Coordination with UNHCR will also be leveraged to facilitate direct engagement with refugees and host communities
to ensure they are aware of, consulted on, and can benefit equitably from, project activities. Finally, the
subcontracting of UNICEF and WHO as implementation partners will strengthen such systems.
99. Other risks (security and data protection) have been identified. Security risk. Several facilities were previously
attacked and looted, leading to deaths of patients and health workers. These risks remain a reality for the World
Bank and partner agencies providing support to health services across South Sudan, particularly in the states of
Upper Nile, Jonglei, and Unity. Multiple effort has been made, however, to mitigate potential risks through the
development of a customized security management plan along with its implementation arrangements. Data
protection. There is a substantial residual risk related to data collection, processing, and privacy during
implementation of the project activities, which may arise from (a) access to personally identifiable and sensitive

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

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VII. RESULTS FRAMEWORK AND MONITORING

@#&OPS~Doctype~OPS^dynamics@padannexresultframework#doctemplate
PDO Indicators by PDO Outcomes

Baseline Period 1 Period 2 Closing Period

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

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Intermediate Indicators by Components

Baseline Period 1 Period 2 Closing Period

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

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19 25 35 43
Percentage of children who have received 1st and 3rd dose of pentavalent vaccine (Percentage)
Sep/2023 Jul/2025 Jul/2026 Jul/2027
75 80 85 90
➢Percentage of refugee children who have received 1st and 3rd dose of pentavalent vaccine (Percentage)
Sep/2023 Jul/2025 Jul/2026 Jul/2027
75 80 85 90
➢Percentage of HC children who have received 1st and 3rd dose of pentavalent vaccine (Percentage)
Sep/2023 Jul/2025 Jul/2026 Jul/2027
75 80 85 90
Percentage of facilities reporting stock out of tracer medicines (Percentage)
Sep/2023 Jul/2025 Jul/2026 Jul/2027
27 26 24 22
➢Percentage of refugee health facilities reporting stock out of tracer medicines (Percentage)
Sep/2023 Jul/2025 Jul/2026 Jul/2027
27 26 24 22
➢Percentage of HC health facilities reporting stock out of tracer medicines (Percentage)
Sep/2023 Jul/2025 Jul/2026 Jul/2027
27 26 24 22
Percentage of children aged <59 months receiving Vitamin A supplements twice a year (Percentage)
Sep/2023 Jul/2025 Jul/2026 Jul/2027
66 70 80 89
➢Percentage of refugee children aged <59 months receiving Vitamin A supplements twice a year (Percentage)
Sep/2023 Jul/2025 Jul/2026 Jul/2027
66 70 80 89
➢Percentage of HC children aged <59 months receiving Vitamin A supplements twice a year (Percentage)
Sep/2023 Jul/2025 Jul/2026 Jul/2027
66 70 80 89
Children under 5 years who are wasted (Percentage)
Sep/2023 Jul/2025 Jul/2026 Jul/2027
16.1 14 12 11
Proportion of infants who have received first dose measles (MCV1) vaccine (Percentage)
Sep/2023 Jul/2025 Jul/2026 Jul/2027
72 75 80 85

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Under ive years’ mortality rate (per 1000 live births) ( ercentage)
Sep/2023 Jul/2025 Jul/2026 Jul/2027
98.69 80 70 60
➢HC under five years’ mortality rate (per 1000 live births) (Percentage)
Sep/2023 Jul/2025 Jul/2026 Jul/2027
98.69 80 70 60
➢Refugee under five years’ mortality rate (per 1000 live births) (Percentage)
Sep/2023 Jul/2025 Jul/2026 Jul/2027
98.69 85 70 60
ntermittent prevention o malaria during pregnancy ( p≥3) ( ercentage)
Sep/2023 Jul/2025 Jul/2026 Jul/2027
11 50 60 75
Maternal mortality ratio (Percentage)
Sep/2023 Jul/2025 Jul/2026 Jul/2027
1223 1000 900 843
➢Maternal mortality ratio for refugees (Percentage)
Sep/2023 Jul/2025 Jul/2026 Jul/2027
1223 1000 900 843
➢Maternal mortality ratio for HC (Percentage)
Sep/2023 Jul/2025 Jul/2026 Jul/2027
1223 900 800 843
Contraceptive prevalence rate (any method) (Percentage)
Sep/2023 Jul/2025 Jul/2026 Jul/2027
6 8 9 10.5
The proportion of patients with suspected malaria who received a parasitologic test (RDT/Microscopy) (Percentage)
Sep/2023 Jul/2025 Jul/2026 Jul/2027
0 80 90 95
Proportion of health facilities that have a core set of relevant essential medicines and commodities available and affordable (Percentage)
Sep/2023 Jul/2025 Jul/2026 Jul/2027
73 75 78 81
BHI training material revised to include refugee sensitive health interventions. (Yes/No)
Sep/2023 Jul/2025 Jul/2026 Jul/2027
No No Yes Yes
Number of health and nutrition services provided to refugees and host communities (Number)

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Sep/2023 Jul/2025 Jul/2026 Jul/2027

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

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South Sudan Health Sector Transformation Project (HSTP)(P181385)

Percentage of states that conducted quarterly coordination meetings with a review of data and documented with minutes including action items and follow-up (Percentage)
Sep/2023 Jul/2025 Jul/2026 Jul/2027
0 30 50 70
Component 4: Contingent Emergency Response Component

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

Monitoring & Evaluation Plan: PDO Indicators by PDO Outcomes

Expand access to basic package of health and nutrition services

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

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

Monitoring & Evaluation Plan: Intermediate Results Indicators by Components

Component 1: Provision of Basic Health Services Nationwide

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

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

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

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

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

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

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

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Description Proportion of an alert about a disease, condition, or event of public health

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

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

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Responsibility for Data WHO; PMU

Collection

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ANNEX 1: Implementation Arrangements and Support Plan

Introduction

1. South Sudan’s health system is systemically underdeveloped, characterized by poor access to health services,
significant shortage of skilled health workers, and difficult operating environment leading to extremely alarming
health outcomes. Under five mortality is 96.2 per 1,000 live births, infant mortality is 62.4 per 1,000 births, and
maternal mortality is estimated at 1,150 per 100,000 births.33 Poor health outcomes are underlined by weak health
service delivery including only 40 percent of births assisted by a skilled provider and 11.5 percent of children between
12 and 23 months of age receiving routine vaccinations.34
2. Fragmentation is a defining features of South Sudan’s health system. Since 2013, health service delivery in South
Sudan has been financed by the HPF, a consortium of donors including the United Kingdom, the United States, Canada,
Sweden, and the European Union (EU) and Gavi, the Vaccine Alliance and administered by the UK Foreign,
Commonwealth and Development Office (FCDO), and the World Bank. While donors have strengthened coordination
between the two areas, the two areas have separate management structures creating inefficiencies and coordination
challenges. Further, the Government’s engagement in health service delivery and financing of the health sector is
minimal and to date, many gaps remain regarding the steward of the sector, including effective coordination and
facilitation among several resources or IPs which led to further sector fragmentation.
3. The pressing resource needs in the sector, combined with the harmonized funding cycles of the largest health sector
development donors, and strengthened leadership in the MoH, are a unique opportunity for the next stage in
integrating health financing and harmonizing health service delivery nationwide in South Sudan, through an IDA
project co-financing arrangements (standalone MDTF and SDTF) to cover health service provision across the country,
in complement to Government resources. Such a pooled fund mechanism is also an opportunity to strengthen the
Government’s role as a steward of the health sector through the gradual shift toward Government contracting of
health service providers and will facilitate operationalizing the concept of one program, one budget, one package of
services, and one reporting mechanism.
4. The proposed trust funds will be managed by the World Bank and would draw on the World Bank’s systems and
experience managing multi and single donor trust funds globally and in South Sudan. The trust funds will reflect the
following design features (Figure 1.1), with the opportunity to further develop the trust fund and contracting
arrangements based on further learnings from current health service delivery modalities of the World Bank and HPF:
• World Bank management of the standalone trust funds using an IPF instrument, through which health sector
donors will pool their resources through Administration Agreements with the IDA funding under one MDTF and
another SDTF managed by the World Bank. In addition, World Bank will sign a Financing Agreement with the MoFP
for the IDA+ trust fund resources to clearly identify government responsibilities and contribution.
• Establishment of a PMU at the MoH to manage health service contracting and the day-to-day engagement with
the Government, management organization, and donors.
• The Government, represented by the PMU, contracts of a management organization which will sub-contract NGOs
to deliver the identified package of health services.

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

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• NGOs sub-contracted by the management organization will deliver the identified package of health services
nationwide as per the required standards.
• TPM agency/ies will conduct household and health facility surveys along with surveys to solicit community and
patient feedback. The TPM agency/ies will submit quarterly monitoring reports directly to the PMU, the World
Bank, and UNICEF.
• An HSC to provide technical strategic direction and guidance on the sectoral challenges and future steps including
service delivery, health financing, HRH, data, and medicines and medical supplies. The HSC will meet on a bi-
annual basis and may invite any party to join the meetings.
• An OSC to provide technical guidance on the management and oversight of project implementation, challenges
and achieved results of the program. The OSC will meet on a quarterly basis and may invite any party to join the
meetings.

Figure 1.1. Structure and Governance

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

Project Management Unit (PMU)

6. The PMU will be responsible for managing health service contracting and the day-to-day engagement and
coordination with the Government, management organizations, donors, and the World Bank. The following are the
key functions for the unit:

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Figure 1.2. PMU Structure

UNDERSECRETSRY
Overall leadership & strategic directions under Steering Committees guidance

PMU MANAGER
Oversee management, coordination, implementation, progress towards desired
results, and provide necessary technical expertise

Technical Support
PROCUREMENT M&E -PHC (MCH focus)
FINANCE Ensure timely and E&S COMMUNICATION
-H. Info./Surv.
efficient availability of Ensure timely &
Ensure quality FM and accurately completion Ensure compliance with Manage internal &
goods, work, Non- -Nutrition
reporting of reporting obligations WB E&S Standards external relations
consulting services, and -HRH
Consulting services as required
-Supply/Pharma.

FIELD OFFICERS

High-Level Steering Committee

High-Level Steering Committee Mandate and Functions

7. The HSC will pursue the following ToRs.

(a) The HSC is mandated to provide strategic direction and guidance on the sectoral challenges and future steps on
service delivery and other health system pillars.
(b) The HSC will oversee and monitor the implementation of the project-approved plans and different processes
including health facilities hand-over plan, plan to expand coverage of health facilities, BHI expansion plan, MoH
capacity-building plan, government and partners’ commitments, and any reprogramming amendments.
(c) Review and approve applications to join project funding and/or activities by other potential interested parties.
(d) The committee will review project data to monitor progress towards achieving desired results, identify needed
actions, and follow-up on actions during meetings.
(e) The committee will ensure the existence and enforcement of effective coordination and communication between
different constituencies and other stakeholders relevant to its mandate.
(f) The committee will mobilize and sustain political commitment to take the necessary actions towards achieving
the development goals and the effective processes.

Membership of the Committee

Constituencies
• Government constituencies: this refers to federal ministries and governmental entities relevant to the health sector
cooperation (nomination to ensure good representation including for state level); and

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• All constituencies and entities’ representation should be from the highest senior level, when possible.

Delegations maybe acceptable based on a prior notice to the rest of the committees for specific sessions.

Structure of the HSC

Table 1.1: High-level Steering Committee Membership

No. The member Position Constituency

1.
Minister of Chair Government
Health
2.
Minister of 2nd Co- Government
Finance and Chair
Planning
3.
Undersecretary, Rapporteur Government
MoH
4.
Undersecretary, Member Government
MoFP
Governance of the Committee

8. All committee decisions will strive to seek consensus on all matters. Committee meetings should be attended by at
least 50 percent of members or their alternates to be valid. The following aspects of governance will be noted by all
members:
• All members should ensure that they provide other members with the appropriate updates on issues related to
the committee mandate and functions within their constituencies.
• The committee may invite any other party to its sessions for discussions.
• All recommendations proposed by the committee will have to go through the World Bank’s prior no objection.

Operational Steering Committee

9. To ensure functionality of the HSC, an OSC will be formulated to complement the mandates of the HSC through
providing guidance on the management and oversight of health service delivery and achieved results of the program.

Operational Steering Committee Mandate and Functions

10. The OSC will pursue the following ToR:
(a) Provide routine oversight and operational direction in line with overall direction from the HSC.
(b) Steer the proposition of any reprogramming amendments when necessary and report timely to the HSC.
(c) Follow up the progress in achieving the targets identified in the Results Framework and M&E plans. Identify
challenges affecting timely and quality implementation and liaise with the HSC to follow up on problem-solving.
(d) Formulate and present findings, reports, and recommendations to the HSC on regular basis.

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(e) Analyze and discuss quarterly follow up reports submitted by the MOs and produce recommendations for the HSC
and respond to queries and clarifications.
(f) The committee may invite any other party to its sessions for discussions.
(g) All recommendations proposed by the committee will have to go through the World Bank’s prior no objection.

Structure of the OSC

Table 1.2: Operational Steering Committee Membership

No. The member Position
1. Undersecretary, MoH Chair
2. Representative MoFP Member
3. 4 Director Generals, MoH Member
4. 2 States MOH representatives Member
5. PMU Manager Rapporteur
* Representation should be from the technical level.
Steering Committees’ Meetings

• The HSC should conduct at least two general meetings per year; however, additional special meetings may be
called by the chair. The OSC shall meet on quarterly basis after project effectiveness. However, during project
preparation and transition, the HSC shall meet on a quarter basis while the OSC shall meet on a monthly basis.
• The calendar of regular meetings shall be prepared by the secretariat and circulated to all members in advance.
• If any member is unable to attend a meeting, he/she will inform the Secretariat in advance to the meeting, and
state that his/her alternate will attend or not. In such circumstances, the alternate member will be the voting
representative.
• Any member can submit items for inclusion in the agenda through the Secretariat.
• The meetings should be moderated by the chair or in the Chair’s absence by the Co-chair.
• A quorum is the presence of at least half of the members or their alternates. If there is no quorum, the Chair has
the right to cancel the meeting.
• At the start of each meeting, the agenda may be modified and must be approved at the meeting by simple
majority.

Steering Committees’ Secretariat

11. The PMU will identify one staff member to act as the committees’ coordinator and will be supported by an
administration assistant. Pending the formation of the official PMU, the MOH and the World Bank will nominate some
members to fulfill that role on a temporary basis.

Secretariat ToRs

• Attend all meetings and any offspring committees in a non-voting capacity and serve as Secretary for these
meetings.
• Prepare meeting agenda after discussion and approval of the Chair.
• Prepare draft minutes and finalize and disseminate approved minutes to all members.

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• Communicate decisions of the committees among and between all members and into any relevant entities
and personnel.
• Follow up on committees’ decisions and recommendations.
• Maintain a log of the committees’ decisions that reflects the confirmed minutes.
• Support and contribute to the committees’ communications, representation, and M&E.

Steering Committees Logistics

12. Unless agreed otherwise, the MoH or the World Bank will host the meetings in their offices in Juba. The secretariat
shall ensure offering options for virtual joining for those unbale to attend physically.

Table 1.3: Roles and responsibilities for each entity and health service contracting arrangements.
Entity Composition Role
Government MoH • Provide stewardship and oversight for the health sector and the HSTP
MoH- PMU • Contract management organization
• M&E functions for the project
Ministry of Finance • Contribute financing for health service delivery
Donors Tentatively current HPF • Contribute financing for health service delivery and other project components
donors, Global Fund, and through the IDA financing and through a stand alone MDTF
World Bank • Discuss the progress reports and advise
Fund Manager World Bank • Pool health service delivery funds from donors
• Develop and oversee the project through which resources will be pooled
• Coordinate donor and Government inputs into project documents and
monitoring reports
• Provide fiduciary, technical, and management oversight for health service
delivery financed by IDA and linked MDTF
High Level Donors, MoH, MoFP, WB, • Provide high level direction for the project
Steering SMoH, UNICEF • Meet every six months
Committee • Review project data, identify needed actions, and follow-up on actions during
meetings
Operational MoH, PMU, World Bank, • Provide routine oversight and operational direction in line with overall
steering Donors, UNICEF direction from the HSC
committee • Meet on a quarterly basis
• Identify and discuss needed actions
• Review project data, identify needed actions, and follow-up on actions during
meetings
UNICEF UNICEF contracted by the • Sub-contract NGOs
PMU • Supervise and support NGOs
• Sub-contract procurement and logistics agency
• Supervise and support logistics agency
• Develop capacity of CHDs
Contracted NGOs sub-contracted by • Deliver health services
Service UNICEF • Engage with communities to support health service delivery
Providers

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Pharmaceutical Competitively selected • Procure pharmaceuticals

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

Flow of Funds, Fiduciary Safeguards, and Monitoring Arrangements

13. The proposed program will build on the World Bank experience with similar structures in South Sudan in other
sectors. The funds for the project interventions and procurement of supplies will flow directly from the World Bank
to UNICEF and WHO, while the fund required for PMU salaries and operating expenses will flow from the World Bank
to the project designated account managed by the Government.
Figure 1.3. Flow of Funds

14. Reporting and monitoring: The PMU, UNICEF, and WHO will submit to the World Bank quarterly financial and
technical progress reports as per the required World Bank templates which will cover areas such as technical and
operational progress, FM, procurement, social and environmental risk management, visibility and communication,
and evaluation on IP performance and corrective actions.

15. UNICEF and WHO will mitigate the FM risks by implementing various measures including ensuring adequate
outreach and implementation through contracted NGO IPs. Due diligence, monitoring and supervision of the IPs will
be conducted in accordance with the Harmonized Approach to Cash Transfers (HACT) framework which involves
programmatic field visits, spot checks and special audits. In addition, the managing organizations country program

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

16. PIM. The PIM will be the key document based on which the project will be implemented. The PIM will be prepared
and adopted by the PMU for the operation to set out detailed guidelines, methods and procedures for the
implementation of the project. The PIM provides: (a) detailed description of the project activities, the sequence of
implementation, and the workplan defining the target dates; (b) institutional structure along with the decision-making
protocols and role and responsibilities of designated staff; (c) budget and budgetary controls; (d) flow of funds,
disbursement procedures and banking arrangements; (e) financial, procurement and accounting procedures; (f)
personal data collection and processing in accordance with applicable national law and good international practice;
(g) M&E arrangements including TPM of project implementation; (h) measures related to the use of security or military
personnel in the implementation of project activities (as described in the projects legal agreements); (i) environmental
and social; and (j) running the data visualization tool with support from the World Bank.

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ANNEX 2: Third Party Monitoring and Data Visualization

1. TPM is critical for an objective understanding of project progress and to collect data to improve service delivery. Along
with monitoring and survey activities, the TPM will develop Government capacity for the design of data collection
tools, data use, and oversight of health service monitoring. To support high-quality data collected in a conflict-
sensitive manner, ToR for health service delivery TPM will be developed to ensure robust supervision as well as data
review to assess and address data quality. Comprehensive ToRs have proven critical to high-quality TPM arrangements
in FCV settings. All TPM will pay close attention to ensuring all language groups in the country are incorporated in
monitoring through translated tools and representative selection of enumerators. Set data entry, reporting, and
presentation formats will be established and used by the TPM. The TPM will be expected to produce quarterly reports
and presentations for national and state level use as well as quarterly reports for IPs detailing results at the facility
level. The TPM will present findings to the State and Federal Level as well as IPs, CHDs, development partners, UNICEF,
and The World Bank. Under this arrangement, TPM will be contracted by the PMU with input and oversight from the
World Bank. TPM arrangements will include the following:
(a) Quarterly TPM visits. All data collection methods will be administered during the same visits, at the frequency
indicated. A phased approach will be used to support the expansion of TPM in the country, with initial sampling
for quarterly and bi-annual assessments moving to a bi-annual census of health facilities once monitoring capacity
is established, anticipated in Year 2. Quarterly TPM visits will incorporate the following:
(i) Quarterly health facility functionality assessments. At baseline and endline, the assessments will
incorporate a sample of operational health facilities not supported by the project to generate
comprehensive information on health service delivery nationwide and the added value of the project.
Measures on disability access will be included in the assessments.
(ii) Quarterly data quality verification to provide measures of partner data quality and reporting accuracy.
(iii) Bi-annual health service quality assessment to capture the quality of key health services, focusing on health
service process and structural quality. On an annual basis the health service quality assessment will include
direct observation of health service process quality measures at hospitals and health centers.
(iv) Bi-annual patient feedback using exit surveys.
(v) Bi-annual visits to a sample of BHTs to measure service outputs and quality.
(b) Periodic TPM data collection:
(i) Biennial household coverage surveys as baseline/endline surveys in the project’s three-year timeframe.35
(ii) Citizen engagement survey collected at the household level, with the coverage survey every other year.

2. Data Analysis and Visualization Platform. The platform will emphasize development of an integrated,
institutionalized, and sustainable system. The platform will include analysis of health service delivery in refugee and
host community areas. The platform will include the following:
(a) Interactive data visualization platform presenting Results Framework and core indicators. The platform will use
data from DHIS2 and the TPM and will include BHI data. It will be updated at least on a quarterly basis.
(b) Presentation of data in data visualization platform in the form of static and interactive maps, charts and graphs,
tailored to project monitoring needs and partner priorities.
(c) Incorporation of HSF data within the data visualization platform through a link or page within the platform.
(d) Overlay of disease and health service delivery data with meteorologic data to better understand seasonal patterns
in service delivery and infectious disease data.

35Given the planned project length of three years, this is a baseline and an endline survey. Potential timeframe changes would include interim surveys, which are
planned to be light surveys focusing on key indicators.

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ANNEX 3: Project Financing Sources by Component36

Initial IDA Additional Resources

Project IDA Trust Total

Project Subcomponents PBA WHR Govt SDTF MDTF
Components Financing Funds

Subcomponent 1.1: Delivery of

high impact basic health and
nutrition services Nationwide
Component 1: through Health Facilities 0 62.67 62.67 10 21.14 179.92 201.06 273.73
Provision of Subcomponent 1.2: Boma Health
Basic Health Initiative 0 3.41 3.41 0.95 8.05 9 12.41
Services Subcomponent 1.3: Last Mile
Nationwide Pharmaceutical Delivery 0 3.41 3.41 1.05 8.95 10 13.41
Subcomponent 1.4: Climate
Resilient Health Service Delivery 10.22 21 31.22 0 0 0 31.22
Component 1 Total 10.22 90.49 100.71 10 23.14 196.92 220.06 330.77
Subcomponent 2.1: Health
emergency preparedness and
response, laboratory
strengthening, and disease control 0.66 1.38 2.04 0.36 3.1 3.46 5.5
Subcomponent 2.2: Blood Banking
Component 2: and Transfusion 0.29 0.64 0.93 0.17 1.4 1.57 2.5
Health Systems Subcomponent 2.3: Health Service
Strengthening Quality Improvement 0.3 0.53 0.83 0.17 1.5 1.67 2.5
Subcomponent 2.4: Health
Management Information Systems 0.3 0.63 0.93 0.17 1.4 1.57 2.5
Subcomponent 2.5: Health Service
Stewardship and Financing 0.23 0.54 0.77 0.13 1.1 1.23 2
Component 2 Total 1.78 3.72 5.5 0 1 8.5 9.5 15
Subcomponent 3.1: Third Party
Monitoring 0 6.15 6.15 0.8 6.8 7.6 13.75
Subcomponent 3.2: Data Analysis
Component 3: and Visualization Platform 0 0.3 0.3 0.05 0.38 0.43 0.73
Monitoring and Subcomponent 3.3: Contract and
Evaluation and Program Management Capacity
Project Development 0 1.54 1.54 0.2 1.7 1.9 3.44
Management Subcomponent 3.4: Project
Management 0 2.8 2.8 0.31 2.7 3.01 5.81
Component 3 Total 0
0 10.79 10.79 1.36 11.58 12.94 23.73
Component 4:
Contingent
Emergency
Response
Component 0 0 0 0 0 0 0
Total Costs 12 105 117 10 25.5 217 242.5 369.5

36
The amounts exclude direct and indirect costs for UNICEF, WHO and WB for MDTF and SDTF.

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ANNEX 4: Refugees and Host Communities

1. The HSTP will provide services to the population of South Sudan through IDA and expected donor financed MDTF
and SDTF funding. Within the scope of the project there is a special focus to continue to address the pressing health
and nutrition needs of refugees and host communities. It includes the following measures:

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

• Expand the provision of the high-impact package of basic health and nutrition services nationwide. The project
expands the provision of services across the country in addition to Maban and Jamjang (which benefited from
previous resources accessed through WHR). This includes Western Equatoria State (Ezo and Yambio Counties),
Central Equatoria (Juba and Yei Counties) and Jonglei State (Pochalla County) which are among the largest refugee-
hosting counties in South Sudan. The support provided takes the form of a gradual replacement of support by
humanitarian agencies (including UNHCR and ICRC) which are pulling back their support from at least 50 health
facilities to cater to other humanitarian priorities (especially Sudan).
• Ensure better strengthened elements of the health care systems that will directly affect maternal and child
mortality rates through WHO implemented activities. The project will support the functionality of state and
district level blood banks and reference laboratories. This will allow enhanced access to those services and directly
decreasing preventable causes of death. In addition, the project will support the expansion of surveillance systems
for early disease detection that would enable timely response to disease outbreaks which is highly relevant to
refuges and host communities’ population.
2. Achievements by the COVID-19 Emergency Response and Health System Preparedness Project (CERHSPP-P176480):
Through the support of WHR, CERHSPP was able to provide the following:
➢ Health and nutrition services to refugees and communities in 4 hospitals, 20 PHCCs, 28 PHCUs and 10 nutrition
facility sites in Upper Nile, Jonglei and Unity states.
➢ Between January and July 2023, 73,937 children were treated for severe wasting.
➢ About 98 percent of eligible population from host communities and 35 percent from refugees have received
COVID-19 vaccine.
➢ About 60 percent of targeted refugees' deliveries were attended by skilled health personnel.
3. Lessons learned: The HSTP will build on the achievements of, and lessons learned from the CERHSPP support to
refugees and host communities as follows:
Table 5.1. Lessons Learned
Lessons Learned HSTP response
There is an urgent need to expand coverage to all areas • Nation-wide focus of project
affected by the refugee movement in the country given • Close coordination with Humanitarian
the pre-existing fragile context. partners

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Focus on demand side activities to generate adequate • Enhanced focus on health literacy and
demand for services is necessary given the contextual updating communication messaging and
challenges and the low literacy rate among the materials in local languages.
population.
Moving from facility based to community/outreach • Expansion in BHI program
mode of service delivery is important to consider given
the difficult context (flooding, movement, and
transportation cost).
The support offered by the humanitarian actors is not • Transition plan established for the handover
sustainable. As of September 2023, different process. This will be monitored by MoH, World
humanitarian actors are in discussion with the to vacate Bank and donor partners.
50 health care facilities catering for the refugees and
their host communities owing to other competing
global priorities, for example, conflict areas in Sudan.
Those facilities will require urgent substitute support to
prevent any interruption in services.

Close coordination between IPs, donors and • All project partners (MoH, World Bank,
humanitarian agencies is of critical importance to donors, UNICEF and WHO) will coordinate
ensure one plan and one strategy for service provision through the two established coordinating
efforts. The refugee community has witnessed bodies, namely: high and technical steering
disproportionally higher levels of disease outbreaks committees.
over the past year. This has required intensified efforts, • Technical steering committee will meet and
and increased demand for costly surveillance, coordinate with the Humanitarian Cluster in
diagnostic and curative services by the IPs. Several South Sudan on a regular basis.
measles, hemorrhagic fever, and schistosomiasis • Coordination links in county and state level
outbreaks were frequently recorded. with other humanitarian partners.

Refugees and their host communities are usually • Enhanced surveillance and early response
subject to inadequate access to food and water, • Introduction of ambulance evacuation
sanitation, and other basic services, increasing their risk services to nearest hospitals.
of communicable diseases, particularly measles and • Improved access to laboratory and blood bank
foodborne and waterborne illnesses. They are also at a services.
higher risk of accidental injuries, hypothermia, burns,
unwanted pregnancy and delivery-related
complications, and various noncommunicable diseases.
This stresses the need for more responsive health care
services that are capable of early detection and
management of those cases.

Health illiteracy is a widespread issue among refugees, • Expansion of BHI program

and only about 40 percent have sufficient knowledge to • Enhanced health and nutrition education
effectively navigate health care systems. The barriers materials.
are important for individuals with disabilities, affecting • Introduction of Sexual and Reproductive
30% of this subgroup. In addition, nearly 50% of women Health Services in the Package (SRH).
and girls in the refugee population struggle to access • Introduction of GBV services.
sexual and gender-based violence protection services.

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Growing Humanitarian Needs in Refugee and Host Communities

4. Since gaining eligibility to the WHR under IDA19, the Government of South Sudan has made important progress in
fostering longer-term benefits for refugee and host communities. First, the Government has allocated some 4,000 ha
of land to refugees for agricultural cultivation, a step taken in support of its Global Refugee Forum pledge of expanding
equitable economic opportunities in refugee-hosting areas. Second, the Government has contributed a significant
number of textbooks to schools serving refugees, a step taken in support of implementing its policy commitment to
full integration of refugees into the national education system. Third, in late 2021, as part of the Solutions Initiative
for South Sudan and Sudan led by the Intergovernmental Authority on Development (IGAD), the Government finalized
its Durable Solutions Strategy and Plan of Action for Refugees, Internally Displaced Persons, Returnees and Host
Communities. Fourth, in September 2022, the Government finalized discussions with the Government of Sudan on
the so-called ‘Four Freedoms’ agreement, which would guarantee people from both countries ‘freedom of residence,
freedom of movement, freedom to undertake economic activity and freedom to acquire and dispose property’. While
these freedoms are not limited to refugees and host communities, their proximity to the border with Sudan means
they would disproportionately benefit refugees and host communities in South Sudan by allowing them to capitalize
on trade networks and broaden economic opportunities on both sides of the border. Finally, the country has continued
to uphold in practice its strong policy commitment to refugee protection, granting refuge not only to the hundreds of
thousands of Sudanese and other refugees who have been in South Sudan since its independence in 2011 but to new
inflows of refugees from recent and ongoing conflicts in Sudan and the Horn of Africa. To ensure South Sudan’s refugee
policy remains robust and continues to improve both de jure and de facto, the World Bank worked with UNHCR and
the Government to prepare a baseline assessment for South Sudan under the Refugee Policy Review Framework that
promotes and monitors the design and implementation of pro-refugee policy over time. Together, these actions
constitute good progress in advancing the strategy South Sudan submitted as part of the IDA20 WHR eligibility process
and in promoting durable solutions for refugees and host communities more broadly.
5. The HSTP will be implemented against the backdrop of a dramatically evolving force displacement landscape in South
Sudan. The continuation of the conflict in Sudan further exacerbates the needs of refugee and host populations.
Wunthow (Juda) border crossing in Upper Nile (near Maban) is the main point of entry for refugees and returnees
arriving from Sudan. When the conflict broke out in April 2023, a large majority of arrivals from Sudan (over 91 per
cent) were South Sudanese returnees. However, since August, there has been a notable increase in refugee arrivals.
As of November 2023, the number of refugees has increased to 17 per cent and analysts expect a continuous uptick
in numbers in the coming months37. Taking a closer look at numbers recorded at Renk border crossing sheds light on
the severity of humanitarian needs in the area. UNHCR notes that the proportion of refugee arrivals in Renk has starkly
increased from an average of 9.5 percent in September, to an average of 52 percent in the first week of
November,2023.38 Further compounding the stress on humanitarian resources, seasonal floods pose additional
challenges to transport and movement of refugees (leading to overcrowding at transit centers).
6. Humanitarian needs have risen significantly with the uptick in the arrival of refugees, particularly as the focus shifts
to addressing evolving needs in Sudan. Over 80 per cent of refugees in Maban and Jamjang are women and children.
UNHCR notes that on average 103 children per month were admitted to health facilities in Upper Nile for moderate
or severe malnutrition between July-August (admissions before the conflict were an average of 40).39 Further WASH

37
UNHCR-IOM Updates on arrivals from Sudan
38 UNHCR Flash Update, Emergency Response Renk, Upper Nile State, November 10, 2023.
39 UNHCR-IOM Updates on arrivals from Sudan

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

7. The current refugee population estimates are as follows:

Table 5.1 Refugee and Asylum-Seeker Population in South Sudan

Source: UNHCR, September 2023

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

Table 5.2 Projected Refugee Population Estimates

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

Consultation with UNHCR

9. The World Bank is working closely with UNHCR and the MoH to ensure South Sudan’s refugee protection framework
remains adequate, including through periodic assessments. UNHCR has provided the World Bank with an overall
positive assessment of South Sudan’s protection framework while highlighting a set of protection-related challenges.
In addition to the legal framework in place, the Government has maintained its policy of granting refugees access to
its territory and installing practical arrangements for their initial reception and registration.
Transition to UNICEF
10. UNICEF, through World Bank support, has developed an operational model where support was complementary to
UNHCR activities through day-to-day coordination. This coordination included areas such as human resources,
warehousing, pharmaceutical supply, nutrition programs and vaccination. This has allowed UNICEF to gather a
firsthand operational knowledge of the specific needs and pre-requisites of those specific communities within the
context of South Sudan. It is worth noting that other donor agencies, for example, FCDO are also providing their
support to communities hosting refugees through UNICEF.

11. UNICEF has started its preparatory work to facilitate its coverage of the anticipated expansion of activities to the
refugees and host community areas, this includes: (a) the development of a strategic framework (in partnership with

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UNHCR and MOH) to address the needs of those specific areas; (b) development of a detailed and timed transition
plan towards the gradual onboarding of the additional 50 facilities that will be handed over by the humanitarian
agencies, the transition will is planned to start on January 2024 and to be completed by June 2024; (c) advanced
procurement of medical supplies and pharmaceuticals is underway based on a commitment letter issued by the World
Bank on May 2023 under the anticipated HSTP to avoid any gaps in service continuity; (d) early selection of IPs (to be
completed by December 2023) to facilitate early and gradual onboarding of the selected partners towards a smooth
transition from the humanitarian agencies; and (e) expansion of local footprint through additional hiring of dedicated
staff to support local county health departments and implementing partners.
Economic Analysis of Supporting Refugees and Host Communities
12. The Economic benefits of investing in health and nutrition services to refugees and host communities are high. The
number of children below 11 years represents more than 40 percent of the refugee population in South Sudan. The
identified package of nutrition services under the project will follow a life cycle approach and will focus on children,
women of reproductive age, and pregnant and lactating women. Those evidence-based services have been proven to
yield high benefit cost ratios. Investing in specific children and maternal nutrition interventions have been estimated
to yield between US$11 and US$35 for each US$1 invested. Not only are investments in nutrition one of the best
value-for-money development actions, but they also lay the groundwork for the success of investments in other
sectors. Therefore, the US$25 million which will be invested in nutrition under the project are expected to yield
between US$275 million to US$875 million worth of benefits and returns to the refugee and host communities.
13. South Sudan registers one of the world’s highest maternal mortalities (1,150 deaths per 100,000) and under five
mortality (100 per 1,000 live births). Assuming that the project will help a conservative reduction in maternal mortality
by 10 percent over the project duration among the refugee and host community population, this will save around
2,700 children under five and 172 women. Applying a conservative statistical value of life for low-income countries
(US$41,756), this will yield an approximate US$120 million in benefits.40
Figure 5.1. Locations of Refugees in South Sudan41

40
Saluja S, et al. BMJ Global Health 2020.
41
The map has been cleared by the map unit on December 5,2023

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

ANNEX 5: Estimated Financial Contribution to the Program by Different Partners42

Indicative amounts for the program

Source Amount Estimated Type of Trust Estimated time for
pledged Equivalent Fund signing Administrative
(original Amount (US$, Agreement
currency) in millions)
millions
EU December 2023 (before
EUR 24.4 26.8 MDTF Board)
Canada CAD 75 55.5 MDTF Spring 2024
FCDO GBP 50 62.5 MDTF May 2024
USAID US$30 30 SDTF March 2024
GAVI • US$10 million by June
2024
US$20 20 MDTF
• US$10 million by June
2026
Global Fund US$53 53 MDTF March 2024
Sweden SEK 260.7 25 MDTF TBD
Total Donors 272.5*
World Bank 117 (105 WHR +
January 2024 (by project
12 PBA) effectiveness)

Possible future
resources from
IDA
Government co- US$10 allocation from
financing 10 General Budget
Total Program Financial gap for the
399.5 plus future immediate needs of the HSTP
before the Board approval (to
resources from be filled during January –
IDA August 2024) is US$242.5
million.
* Includes cost recovery and World Bank-executed portions

42 The table illustrates the estimated total amounts that are to be contributed from different sources over the lifetime of the project.

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