HNP Knowledge Brief on Strengthening Service Delivery Resilience in FCV Settings Case: South Sudan Key Question: What models of alternative implementation arrangements for supporting health service delivery in FCV settings can be designed when traditional approaches don’t work? Due to South Sudan’s protracted crisis, South Sudan’s health system has long been dependent on external support to deliver basic health services. Based on experiences in the former states of Upper Nile and Jonglei, the World Bank sought to explore several issues though this activity: 1. Factors that have impeded gains in improving access to health care, with a particular focus on project implementation arrangements; 2. How can Results-Based Financing be tailored to the specific context of South Sudan to address the factors affecting service delivery; and 3. How non-traditional and non-state actors can potentially be mobilized to address both emergency health needs of the population and contribute to system strengthening and resilience Lessons learned: On factors impeding service delivery: ▪ Although the Coordination and Service Delivery Organization (CSDO) model introduced by the Health Rapid Results Project (HRRP) was designed before the December 2013 crisis to respond to the context of endemic violence, limited access and infrastructure, and population mobility, the upsurge in violence has led to an increased need for life- saving health services in a context where insecurity and instability have generated additional challenges in providing support. ▪ While HRRP has contributed positively to providing health services in the two former states, results from the project show that coverage remained ineffective due to: (i) upsurge in instability and violence, reducing the CSDO’s ability to provide services; (ii) inability to monitor and verify results in opposition-held territory and insecure locations; (iii) perceived (and probable) non-neutrality in service delivery support across areas held by the government and opposition forces; and (iv) limited oversight and ability of the government to provide satisfactory justification/evidence of supplies, drugs and services arriving at their intended destination. ▪ Implementation by the Ministry of Health has also contributed to attenuated project outcomes due to several constrains: (i) continual payment delays to the CSDO due to the MOH providing incomplete documentation and justification for payment; (ii) passive contract management and insufficient oversight by the MOH, including lack of clarity on the extent to which services are supported in conflict-affected and opposition-held areas; and (iii) challenges related to fiduciary compliance that have grown over time. On Results Based Financing in South Sudan: ▪ Despite initial interest, after several discussions in-country and an opportunity to send a delegation to an in-depth training course on RBF, the senior leadership of the Ministry of Health expressed little interest in exploring the development of an RBF pilot in the country. As such government officials did not attend the RBF training course, which was a precursor to ensuring that the feasibility study and pilot design be developed with strong ownership by the MOH. As such activities related to RBF were not pursued further. On alternative implementation arrangements to support health service delivery: ▪ It was concluded that for future Bank engagement in South Sudan’s health sector, a different mix of approaches would be needed to support health services to the extent necessary in inaccessible areas affected by conflict or held by the opposition. UNICEF and ICRC were identified as uniquely placed in accessing the people who need immediate assistance within the territory of South Sudan and to implement the Project. Selecting both agencies will bring together diverse agencies from both the development and humanitarian service delivery segments and leverage their comparative advantages to ensure services are delivered to target populations in a neutral, flexible and rapid manner, with a particular focus on at-risk and vulnerable populations. The importance of leveraging these actors and providing an immediate flow of funds is necessary to sustain existing momentum and to scale up ongoing activities while avoiding interruption to service delivery supported by HRRP. ▪ A weeklong deep dive within ICRC’s South Sudan country delegation was conducted in August 2018, which helped the Bank and ICRC understand better each organization’s mission goals, their operations, and how they can work together to address the acute health needs in the country. Once the key design elements for activities to be implemented by ICRC were identified and agreed upon by the Bank and ICRC, a mission to ICRC headquarters in Geneva was conducted in October 2018 (consisting of experts from OPCS, LEGAM, Governance, HNP, GSURR, etc.) to iron out the alternative implementation arrangements to be applied by the new approach and implications for the Bank and ICRC. Topics covered operational policies, legal aspects, fiduciary arrangements, social and environmental safeguards, and technical design elements. The mission led to the identification of all the areas where potential waivers from operational policies and guidelines may be needed to allow for the unconventional approach proposed through the operation. ▪ The newly designed implementation arrangements will contribute to ensuring continuity in the provision of essential 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 monitoring and evaluation arrangements for the new approach focus on accountability for results in the delivery of health services. In addition to internal monitoring and reporting mechanisms of UNICEF and ICRC, the new arrangements will deploy to accessible areas an independent monitoring system to assess project implementation and impact in areas where monitoring activities are possible to conduct, where issues related to security and confidentiality are less of a concern. Monitoring activities will provide information to drive strategic planning and response, encourage partner accountability, and inform targeted distribution of health resource and delivery of health services. The major output of the third-party monitoring will be to provide a definitive, reliable, and up-to-date database and information products on health service availability in South Sudan. To strengthen monitoring activities in the project zones the project will harness disruptive technologies for FCV contexts in collaboration with the Geo-enabling for Monitoring and Supervision (GEMS) initiative (P167344). ▪ Given the accessibility challenges and confidentiality issues that arise in the geographical areas supported by ICRC, it was deemed unrealistic and inappropriate for an external monitoring agent to engage in these areas. Given that beneficiaries of support from ICRC will often be residing in opposition-held areas, or affected by active conflict, when developing monitoring mechanisms for the operation, the project will be particularly mindful of the sensitivity around data harvesting, processing, storage and use, putting the potential threat this could expose the affected population to at the forefront of the intervention. ▪ Monitoring arrangements for these areas will triangulate data, to produce a robust monitoring and reporting platform that tracks results achieved in health facilities supported by the operation. These will include both corroboration of 'hard' inputs (i.e. that health care facilities do exist and that medical supplies have been provided for their functioning), and corroboration of 'soft' inputs (i.e. that health care facilities have been benefitting from ICRC staff's expertise and support).