Ministry of Health, Government of Southern Sudan. Basic Package of Health and Nutrition Services For Southern Sudan

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1 Ministry of Health, Government of Southern Sudan Basic Package of Health and Nutrition Services For Southern Sudan Final Draft January 2009

2 ACKNOWLEDGMENT The review of Basic Package of Health Services (BPHS) for Southern Sudan has been made possible through the combined efforts of many organizations and individuals. First and foremost, financial and technical assistance provided by International Bank for Reconstruction and Development the World Bank (WB). Let me take this early opportunity to express profound gratitude to the Dr. Nathan Atem, the Director General Primary Health Care and his entire team for leading the review process that reqired much patience and concentration. Special thanks go Dr. Makur Kariom, the director Reproductive Health (RH-PHC), Dr. Antony Lako, the Director Community Base Health Care (CBHC-PHC), Dr. Lueth Garang, the Director Health Education and Promotion (HEP-PHC) for devoting time to make technical input in the document. I wish to specially mention Ms. Janet Michael, the Director General Nursing Services for her committed advocacy for maternal services within the BPHS, given the challenge of maternal mortality in Southern Sudan. Let me also take the opportunity to specially thank Dr. John Rumunu, the Director General, Preventive Health and his entire team in setting the pace in linking the BPHS to the strategies for the common endemic infection programs and with him, Dr Thabo Othwonh, the Manager Malaria Program, Dr. Rober Azairwe, the Team Leader MSH and advisor Malaria Program, to the different directorates entire Southern Sudan Health fraternity for the Nutrition and the Reproductive Health Technical Working Groups their tireless efforts in reviewing and making most valuable technical contributions to the editing of this document. The ministry also recognizes contributions from Dr. Olivia Lomoro, the DG Health Research, Policy, Planning and systems development, Dr. Richard Lagu, Dr. George Rae and the entire staff of the directorate. Other significant contributions came from Ms. Victoria Jaba Eluzai, Dr. Ayat Jervas, Mr, Samwel Makoy, Mr. Ali Ngor, Dr. Yatta Lugor and Dr. Stanley Ambajoro, MS. Bibian Alex Lotio, Catherine Jurua Otto and Rebbecca Alum William Special thanks go to Dr. John Alwar for ensuring comprehensiveness and sound technical edit of the final version of this the document and to Dr. Chris Lewis, Tearfund, Ms. Marcie Cook, PSI and Dr. Tessa Matholie, Malaria Consortium who assisted with editing the second draft of the document. The Staff of Southern Sudan Offices of United Nations Fund for Population Activities (UNFPA), World Health Organization (WHO), and the International Committee of the Red Cross (ICRC), Sudan Health Transformation (SHTP), Management Sciences for Health (MSH) and Help Age International, made specific inputs to ensure the document is in line with the Interim Health Policy of Sothern Sudan and international state of the art practices in Primary Health Care. Thank you all. Dr. Majok Yak Majok The Under Secretary, Ministry of Health, Government of Southern Sudan 2

3 Foreword Following the signing of the Comprehensive Peace Agreement (CPA) on January 9 th, 2005, the SPLA/SPLM committed itself to establishing a right based approach to development facilitation. The interim Constitution Guarantees every Southern Sudanese the right optimal health. The Government of South Sudan (GoSS) has therefore developed a health policy founded on the Primary Health Care (PHC) as the strategy to make quality health care universally accessible. This policy will form an integral part of the country's development program to ensure rapid improvement of health of the Southern Sudanese. The PHC approach considers full community involvement in decision making as the key to successful provision of health services. This in turn requires a gender balanced representation in the structure for health services governance from the grass root to the GoSS levels. Ongoing health sector reforms is adapting of priority actions and interventions which will most efficiently and effectively reduce mortality, disability and morbidity. The interventions will be made equitably available and accessible at costs that are affordable to the government and the communities and families. Whereas low cost health interventions that can be delivered with very humble technology have been developed, they require efficient managerial systems for their impact to be realized. The current development of the health system takes a two tier approach. The first is the development of sound systems for planning, management, monitoring and evaluation. The second is the concurrent delivery of priority services that address the priority health problems. This document provides guidelines, which will help health service managers, and providers at different levels, the village, the primary health care units (PHCU), the primary health care centers (PHCCs), the county health department (CHD) and the state Ministries of Health (SMoH) in implementing various components of the Basic Package of Health Services (BPHS). The SMoHs and CHDs have the responsibility of ensuring the implementers of health programs are trained in and use this package in evidence based planning and realistic budgeting for effective health service delivery. The objective of having a package is to offer services, which maximize value for money by achieving greater health improvements. It is my hope and conviction that the implementation of BPHS will increase access to quality essential health services and expedite progress towards the attainment of the MDGs in Southern Sudan. To ensure equity of quality care the establishment of levels of services, with their packages especially in Maternal and child health have taken into consideration the unique geographical, climatic and spatial population distribution features of Southern Sudan. H.E. Dr. Joseph Manytuil Wejang Minister of Health Government of Southern Sudan 3

4 TABLE OF CONTENTS ACKNOWLEDGMENT...2 Foreword...3 TABLE OF CONTENTS...4 ABREVIATIONS AND ACRONYMS INTRODUCTION COUNTRY BACKGROUND Land and People State of Health and Health Services in Southern Sudanese BASIC PACKAGE OF HEALTH SERVICES (BPHS) Overview The Purpose of BPHS The Values and Principles COMPONENTS OF THE BASIC PACKAGE OF HEALTH SERVICE Overview Integrated Reproductive Health Services (IRHS) Essential Obstetric Care (EOC) Family Planning and Women s Health (FP/WH) Adolescent Sexual Reproductive Health Services (ASRHS) Men s Reproductive Health Services (MRHS) Integrated Essential Child Health Care (IECHC) Community Based Child Survival Program (CBCSP) Expanded Program on Immunization (EPI) Essential Nutrition Action (ENA) Home treatment of Malaria, Diarrhoea and Pneumonia Management of endemic Common Endemic Diseases (MCED) Malaria Diarrhea, enteric infections and infestations Acute Respiratory Infection (ARI) Neglected Tropical Diseases (NTD) Primary Eye Care and Visual Health Oral Health Mental health

5 Community based prevention and care for common injuries and rehabilitation Integrated Disease Surveillance and Response (IDSR) Health Education and Promotion The Promotion of health seeking behavior - targeting epidemiological priorities Basic package of health and nutrition for Schools Community based nutrition and food security program (CBNFSP) Community management of environmental health and hygiene (CMEH)...27 At work place, CMEH will develop Healthy Workplaces activities to promote and protect the health and safety of people at work by preventing workplacerelated fatalities, illnesses, injuries, and personal health risks. These will include gender relationships and perspectives at work place using STI and HIV/AIDS as entry points. Training in prevention and first aid for physical injuries and snake-bite are highly relevant to the situation in Southern Sudan. Other work place interventions will target lifestyle related diseases including obesity, high blood pressure and diabetes. Healthy healthcare settings are absolutely essential to successful health promotion programs. Again, HIV/AIDS as one of the health workplace programs will be useful entry points Monitoring and evaluation Health Management Information System (HMIS) Periodic M/E Operational research...29 The bulk of health problems and health systems challenges in developing countries lie at the primary level. A significant number of these require operational research to establish causalities and consequences. Much operational research currently takes place in Southern Sudan, both initiated from within the country and from outside. However, there is no existing mechanism for quality control to ensure reliable evidence and no existing forum for disseminating findings and for ensuring that findings filter through into improved policy and practice. The GoSS-MoH has established a Directorate of Research, Planning and Health System Development (DRPHSD) which is responsible for operations research. This should inform planning to ensure cost-effectiveness and attainment of objectives. The BPHS lead agents, together with the research unit within the DRPHSD, will work together to coordinate and housing proposals and study reports, with an improved database of research-related activities relevant to each state whether the proposals originate from within or outside Southern Sudan...29 Table1. BPHS at a Glance

6 Table2. Summary of Integrated Reproductive Health Care (IRHC) Emergency Obstetric and Neonatal Care (EmOMNC) SERVICE NORMS AND STANDARDS BY LEVELS OF CARE Overview Village Level Primary Health Care Units (PHCUs) The Basic Emergency Obstetric and Neonatal Care Primary Health Care Centre (BEmONCPHCC) Comprehensive EmONC Primary Health Care Centre (CEPHCC) Boma Health Committees (BHCs) The County Health Department MANAGEMENT AND ADMINISTRATIVE ARRANGEMENTS Management Logistics Establish functioning logistics system for efficient delivery of BPHS Extending the national health management information system (HMIS)...45 BIBLIOGRAPHY

7 LIST OF TABLES Table1. BPHS at a Glance Table2. Summary of Integrated Reproductive Health Care (IRHC) Emergency Obstetric and Neonatal Care (EmOMNC) Table3. Summary of Integrated Reproductive Health Care (CERH2) Preventive Reproductive Health Services (PRHS) 30 Table4. Summary of CBHC1 - Integrated Essential Child Health Care..31 7

8 ACT ASRH ARI BCC BEMoNC CBHC CEMoNC CHD CHW CMOH CPR EmONC EWARN GAM GAVI GFATM GOSS HAT HHP HMIS HNCG IMCI ITN IEC IECHC IPT JAM LF LLINs MCH MDG MDTF MRHS MICS MISP MoH MUAC MVA NGO NID NTDs OF ORS PICT PMTCT SBA SSRRC STI ABREVIATIONS AND ACRONYMS Artemisinin-based Combination Treatment Adolescent Sexual and Reproductive Health Acute Respiratory Infection Behavioral Change and Communication Basic Emergency Obstetrics and Neonatal Care Community Based Health Care Comprehensive Emergency Obstetrics and Neonatal Care County Health Department Community Health Worker County Medical Officer of Health Contraceptive Prevalence Rate Emergency Obstetric and Neonatal Care Early Warning Alert and Response Network Global Acute Malnutrition Global Alliance for Vaccines and Immunization Global Fund for AIDS, Tuberculosis and Malaria Government of Southern Sudan Human African Trypanosomiasis Home Health Promoter Health Management and Information System Health and Nutrition Consultative Group Integrated Management of Childhood Illnesses Insecticide Treated Net Information, Education and Communication Integrated Essential Child Health Care Intermittent Preventive Treatment (of malaria) Joint Assessment Mission Lymphatic Filariasis Long-Lasting Insecticide-Treated Nets Maternal and Child Health Millennium Development Goal Multi-Donor Trust Fund Men s Reproductive Health Services (MRHS) Multiple Indicator Cluster Survey Minimum Initial Service Package Ministry of Health Mid Upper Arm Circumference Manual Vacuum Aspiration Non-Governmental Organization National Immunization Day Neglected Tropical Diseases Obstetric Fistula Oral Rehydration Solution Provide initiated Counseling and testing Prevention of Mother to Child Transmission (of HIV) Skilled Birth Attendant Southern Sudan Relief and Rehabilitation Commission Sexually Transmitted Infection 8

9 WRHS Women s Reproductive Health Services (WRHS) 1. INTRODUCTION Healthcare is essential for the improvement of the standard of living in any nation and primary healthcare is the focus for action since it can be made universally accessible through a community based approach to health service delivery. The major gaps in health care currently are the availability, accessibility and efficient management of service provision. In the urban fringe and the rural areas this translates to time, cost, comfort, convenience and safety, all of which may affect care seeking practices and the demand for modern health care. A health system in which the lower facilities that can offer low cost effective services function poorly results in the overload of higher hierarchy of health facilities where service provision is more expensive thereby overburdening the national health budget. It also decreases the efficiency and effectiveness of health services and health programs because delays in simple health interventions result in life threatening complications leading to high fatality rates of severe disabilities. Currently the development of health facilities network in Southern Sudan takes and ad-hoc growth pattern and does not consider the geographical terrain or population factors. In addition health inequalities are perpetuated by difference in economic standards of the people. The Basic Package of Health Services (BPHS) in Southern Sudan is developed as the medium term strategy to promulgate the long term Health Policy (HP) of the Ministry of Health (MoH) Government of south Sudan (GoSS) that is founded on Primary Health Care (PHC). It comprises a selection of the most cost-effective elements of PHC to be delivered in an integrated way to enhance progress towards the Millennium Development Goals (MDG). BPHS sets health service delivery norms and standards to guide planning, implementation, monitoring and evaluation at the community, Primary Health Care Unit (PHCU), Primary Health Care Center (PHCC), and by the County Health Department. The document contextualizes BPHS to Southern Sudan, positions health service provision within the overall economic and social development framework, and relates it to similar programs in other countries to enable international comparison. This introduction section guides the reader through the rest of the document, outlining the contents of each section to enable quick reference for a busy health planning session. It also guides health workers to refer and quickly obtain information. Section 2 provides country background, helping the health workers and health program mangers to develop strategic and operational health plans that are relevant to local situations in Southern Sudan. Section 3 outlines the goal, objectives and the principles of the Southern Sudan health policy that are incorporated into the BPHS. It also links BPHS to referral health services and to activities of other sectors whose positive outcomes result in prevention of disease and improvement of health. Section 4 presents the components of BPHS, specifying services integrated into priority actions and clustered four areas, (i) Integrated Reproductive Health Care (IRHC), (ii) Community Based Health and Nutrition Care (CBHNC), with emphasis on child health and nutrition, (iii) Health Education and Promotion (HEP). Section 5 presents the Norms and Standards of service provision and management, presenting the service packages and standards in short narratives and summarizing them in matrices for ease of reference. Section 6 Presents the Management and Administrative Arrangements, summarizing stewardship and oversight issues and providing guidelines for monitoring and evaluation (M/E). This should enable the State and County Health Authorities to provide effective technical support to all agencies providing and coordinating service delivery. It also facilitates and timely easy reporting for all health activities from community to state levels. 9

10 2. COUNTRY BACKGROUND 2.1. Land and People The Comprehensive Peace Agreement of January 9, 2005 created a decentralized structure of government in which there are three levels of political governance in Sudan. These are the Government of National Unity(GNU), the Government of Southern Sudan (GoSS) and the State Governments. The information included in this section is a summary of the geographical position, administrative structure, a short overview on the ethnic and cultural diversity and a summary of the health status in Southern Sudan to help the health workers to link the essential packages with the priority health problems. Southern Sudan covers approximately 640,000 square kilometers (km 2 ), and lies between 25 0 to 30 0 east longitude and 4 0 to 12 0 north latitude. It boarders Ethiopia to the East, Kenya and Uganda to the South, the Democratic republic of Congo to the South West and the Central African Republic to the West, and therefore lies within the Meningococcal belt of the African Continent. Southern Sudan is divided into ten states 1 79 counties and 514 administrative Payams and 2,159 Bomas. The latter comprise clusters of households or villages which form the smallest formal administrative units. Southern Sudan has widely contrasting terrain with vast low lying plains that easily flood during the long rainy season between April and November of each year and Mountainous area to the north and to the west that easily drain after rains. Southern Sudan is traversed by many rivers and streams. Significantly large areas of the country are swampy marshland or become flooded in the rainy seasons. This forms a rich ecosystem for a number of human parasites and vectors that cause serious disease. The road network in Southern Sudan is poorly developed and transportation is further made worse by the terrain and the climatic features. This seriously constrains referral in cases of medical emergency and as such needs a fairly comprehensive PHC. The population of Southern Sudan is estimated at 9,480,000 and expected to increase to 12 million by 2010 owing to high rate of natural growth and the return of refugees from neighboring countries and internally displaced populations located in Northern Sudan. There are 300 ethnic groups in southern Sudan. Centrally, eastwards and to a significant proportion of the South, the predominant culture is nomadic pastoralist, but there are significant sedentary farming groups. Moreover, sedentary practices are increasingly emerging with resettlement after the protracted war. Thus Southern Sudan has wide variation in cultural beliefs and traditional practices on the one hand and a rapid transition through affluence, a factor that has significant health implications. Southern Sudan is one of the poorest countries in the world, although prospects of oil revenue promise future economic improvement. With few exceptions, population density is low, presenting some serious constraints in the distribution of health care personnel and commodities State of Health and Health Services in Southern Sudanese According to the Sudan Household Health Survey (SHHS) of 2006, the infant mortality rate in Southern Sudan is 102/1,000 live births and the under-five mortality rate is 135/1,000 live births, being the highest in the world. Child malnutrition is endemic, 32.98% of under-fives are underweight, 13.5% of them severely, another 22.04%, have moderate and 7.25% severe wasting; and Only 17.03% of under-fives are fully immunized. The Southern Sudan Household Health Survey (SSHHS) of 2006 estimated maternal 1 Western Equatoria, Central Equatoria, Eastern Equatoria, Northern Bahr el Ghazal, Western Bahr el Ghazal, Lakes, Warrap, Jonglei, Unity and Upper Nile. 10

11 mortality ratio (MMR) at 2054/100,000 live births. The antenatal care attendance rate is very low. Only 16.4% of all expectant women attend at least one antenatal care from a health professional. Moreover, only 31.73% of mothers receive at least two doses of tetanus toxoid vaccine during pregnancy. All these lead to a high maternal mortality ratio of 2054/100,000 live births. Less than half (48%) of people in South Sudan use improved drinking water, and only 6.4% of the population uses sanitary means of excreta disposal. A range of rare tropical diseases remain endemic in Southern Sudan under the name neglected diseases. HIV prevalence estimates from location-specific surveys range from 0-8% among adults, but the available information suggests that adult prevalence in significant number of areas has exceeded 1% and continues to increase. The annual incidence of tuberculosis in South Sudan is estimated at 325 per 100,000 populations, among the highest rates in the world. United Nations (UN) agencies and Non Governmental Organizations (NGOs) played key roles in health service provision in Southern Sudan over the latter period of the war. The interventions focused on firstlevel health services that typify humanitarian action. Such service provision approach was inherited by the GoSS-MoH as it was all that existed in Southern Sudan. As a result, the overall access to health care remains below 25% of the population, with user rates estimated to be as low as 0.2 contacts per person per year. Traditional medicine is practiced either out of conviction or because no other means of care are available and private for-profit sector is minimal and do not play a big role in health service delivery and is unlikely to do so in the near future. Overall access to sustained quality health care is poor, with very few communities living within the reach the most basic health services. The material resources and managerial expertise for administering the sector are insufficient and largely dependent on external financial and technical assistance. Existing health infrastructure and equipment are extremely poor, with many hospitals and health centers either dilapidated or only have the capacity and characteristics of lower-level facilities. In addition, the facilities are unequally distributed among the regions. On average, in rural areas, there are about 14,000 people per health unit and 75,000 per health center. There are about 400,000 people per hospital; a recent inventory of hospitals in South Sudan describes a heavy, largely derelict infrastructure. Less than 10% of children under the age of five years have access to immunization services. Indeed most immunization services are still provided by mobile teams at outreach posts. Among the expectant mothers, only 23.11% of expectant mothers receive antenatal care from skilled health personnel and only 13.6% deliver in health institution where only % are cared for by skilled health personnel. Contraceptive Prevalence Rate (CPR) stands at a 3.5% only. At present, MoH has certain advantages and opportunities for strengthening management and restoring services: The official launch of the Health Policy for the Government of Southern Sudan in December 2007 and the building on the cumulative policies and strategies since 1997 coupled with more effective partnership among the health authorities and international partners, provide a strong foundation upon which a modern sector-wide health care delivery system can be developed. This document provides guidelines for development of the Basic Package of Health Services (BPHS) for the delivery of essential health interventions from the household level to the PHCC level, with managerial and technical support from the State MoH and the County Health Department and the referral hospitals. It also provides the opportunity for planning and developing critical infrastructure from which basic and comprehensive Emergency Obstetric and Neonatal Care (EmONC) and Integrated Essential Child Health Care/ Integrated Management of Childhood Illnesses (IECHC/IMCI) can be made readily accessible to mothers and children. Once this is achieved, the services for adolescents and adults are easily added as the most essential requirements to deliver them are already provided for, by the maternal and child health services thereby providing universal access to health care. 11

12 3.1. Overview 3. BASIC PACKAGE OF HEALTH SERVICES (BPHS) The last two decades have seen the emergence of a significant number of low cost technologies and approaches to support the effective delivery of PHC in the remotest of locations of the world. Southern Sudan missed the opportunity to join with the rest of the world in the adoption of such technologies and approaches because of a prolonged war and struggle for justice. Following the signing of CPA, a Multi- Donor Trust Fund (MDTF) was set up to channel resources to stimulate growth and development both in the Northern and Southern Sudan. Within this framework, the Umbrella Program for Health Systems Development (UPHSD) was established to develop core health sector systems and capabilities and increase population access to basic health services. BPHS is the service delivery components of UPHSD The Purpose of BPHS The BPHS is the medium term strategy to implement the health policy of the GoSS. It is a guide that enables providers to plan integrated and holistic health services from the community level to the Comprehensive Emergency Obstetric and Neonatal Care Primary Health Care Center (CEmONCPHCC) level and link them to a rational hierarchical referral system because health problems of individuals and communities are often multiple. It also enables the development of comprehensive continuum of preventive health care organized in life-cycle order from conception to old age. The document provides a means to establish good organization, logistics and competent staffing that are prerequisite to successful performance. The BPHS will help individual professionals to assess their own capabilities against the service norms and standards for each level of care and the competency required to deliver them effectively, and become an incentive for continued education. The document helps service managers and health worker trainers to identify skill and knowledge requirements and gauge it against performance to develop more effective oversight, support and training curricula training curricula to update the capabilities of health staffs. Other professional tasks not directly related to individual patient care but necessary for quality and aesthetics to improve the health of their local communities are included to help health service managers define support needed for provision of quality primary health care. The BPHS comprises a selection of interventions for diseases prevention and health promotion, rehabilitation and selected curative services that address priority health problems integrated in a way that makes it accessible at appropriate levels of care at affordable cost to: Improve maternal and child health Control communicable diseases Improve of community nutrition, especially mothers and children Control the most common non communicable diseases. The term Basic Package of Health Services (BPHS) is used to refer to the PHC component of health services that is part of a comprehensive package of care continuum in Southern Sudan. It is synonymous to essential health service package (EHSP) or minimum packages of health services (MPHS). The BPHS is linked to the referral health services and to activities of other sectors that are are relevant to preventive promotive health care, such as Agriculture, Education, Environmental Management, Gender, Social Welfare, Culture and Religious Affairs, that contribute directly to health outcomes, thereby creating opportunities for collaboration in planning and service delivery to mutually synergize and enhance the progress towards MDGs. 12

13 The Goal The Basic Package of Health Services (BPHS) contributes to the GoSS-Health Policy goal of Promotion of equitable access to essential health services. The intention is to strengthen health systems while scaling up efficient, effective and sustainable provision of health services to attain rapid reduction in burden of disease thereby reducing poverty among the people of South Sudan The Objectives 1. To increase access to PHC services from 25% to 50% by To improve the quality of care through the delivery of specified norms and standards of services. 3. To strengthen the management of health services through capacity strengthening for State Ministries of Health, County Health Departments, and Payam Health Departments The Values and Principles The Basic Package of Health Services ascribes to the values of the GoSS health policy of, the right to health equity, pro-poor, community ownership, good stewardship and good governance. The principles of BPHS are: community participation, enhanced first level care, strengthened rational referral services and intersectoral collaboration Community Participation Community members are to be empowered to take greater responsibility for their health. They are to be sensitized to identify their health priorities, mobilize, allocate and manage locally available resources to carry health activities that they are technically competent to implement, monitor and evaluate with support from community based extension service agents from health and collaborating sectors Enhanced first level care Essential health services must be available within the reach of the population. At community level, maternal and child health workers (MCHW) and household health promoters (HHHP), working under the direct supervision of Village Midwives (VMW) and community health workers (CHW), attached to a primary health care units (PHCU), with support from community health extension workers (CHEWs) and village healthy committees, will support household members in implementing selected simple and effective health interventions Strengthened referral system Provision of the BPHS is backed by services from the County, State and the teaching Hospitals, together with those of the State and Central Public Health Laboratories to cater for clients with more serious or relatively rare health needs. County hospitals and are responsible for oversight, technical support and capacity strengthening especially in diagnostic and curative related services at household, PHCUs and PHCCs. The County Health Departments (CHDs) are responsible for all community based health activities within communities. CHD and hospital staffs are therefore all members of the county health management teams (CHMT). This is to ensure rational referral and that hospital-based resources strengthen the delivery of BPHS Intersectoral collaboration BPHS recognizes the importance of all the sectors in improvement of health and encourage joint implementation of development initiatives that impact the health of people in Southern Sudan. 13

14 4.1. Overview 4. COMPONENTS OF THE BASIC PACKAGE OF HEALTH SERVICE The basic package of health services (BPHS) provides the service norms for four levels of care, Village level Health Care, Primary Health Care Unit (PHCU), Primary Health Care Centre (PHCC) and County Health Department (CHD). This section of the document defines the roles and describes the services to help in the planning, acquisition of essential equipment and commodities, and to put in place the organization and logistics required for effective delivery of services. The BPHS will deliver four service components. Services for each component in turn address the most urgent health priorities (those that result in the highest numbers of deaths and disability) and management systems to support helath intervention initiatives, clustered as follows: 1. Integrated Reproductive Health Care 2. Community Based Health and Nutrition Care 3. Health Education and Promotion 4. Management, Oversight, Monitoring and Evaluation Specific programs have been developed by the different directorates in GoSS-MoH based on comprehensive policies, operational guidelines, procedures and protocols to ensure the quality services under their respective mandates. These services are integrated into the care elements and services to be delivered through BPHS. For each of the service areas, a summary description is provided that explains the tenets of the proposed services and the expected targets of the medium term health strategies and responses. This section links BPHS with strategies proposed by the different directorates of GoSS-MoH to keep PHC and other health initiatives and activities in tandem Integrated Reproductive Health Services (IRHS) Integrated Reproductive Health Services (IRHS) are established to maintain reproductive health through informed choices of gendered, safe, reproductive and sexual practices. The services include Essontial Obstetric Care (EOC), Women s Reproductive Health Services (WRHS), Adolescent Sexual and Reproductive Health Services (ASRH) and Men s Reproductive Health Services (MRHS) Essential Obstetric Care (EOC) The Southern Sudan Household Health Survey (SSHHS) of 2006 estimated maternal mortality ratio (MMR) at 2054/100,000 live births. Given the current estimated population of 9.7 million and a rate of natural growth of approximately 4%, this translates to severe complications in 76,000 young Southern Sudanese mothers during pregnancy and child birth, with close to 10,600 dying every year. For each of these mothers, the risk of their baby dying within the first year of life is three times that of other babies. Yet the causes of these deaths are nearly all preventable. Because of this the GoSS has highly prioritized maternal and child health. Preventive and promotive maternal and child health services are therefore the centerpiece of PHC services and the BPHS. Essential Obstetric Care in Southern Sudan is modeled around establishment of readily accessible quality Emergency Obstetric and Neonatal Care. EmONC is a focused care approach during pregnancy, delivery and in the postpartum period. The objective of EmONC is to reduce maternal mortality ratio (MMR) by 20% to 1630 per 100,000 live births by

15 and by a further 20% by the beginning of 2012 to less than 1300 per 100,000 live births. This will be done by increasing the number of women delivering in health facilities and overseen by skilled birth attendants from 14.75% to 20% by 2010 and to 30% by In order to achieve this, the number of health facilities will be developed to raise the access to basic and comprehensive EmONC from the current 13.6% by 20% (to 36.6%) in 2010 and by a further 20% to (56.6%) by EmONC comprises the minimum initial service package (MISP) for Reproductive Health (RH) and emergency preparedness and response. The EmONC services include: (i) counseling for early identification of pregnancy, seeking and compliance with antenatal care; (ii) focused antenatal care based on the principles of standard obstetric care (SOC), which aims at early initiation of antenatal care and attendance of at least 4 antenatal care sessions by all mothers. This should enable early identify and referral of high risk pregnancies for management by skilled health professionals; (iii) nutrition education and support for expectant and postnatal mothers, (iv) Skilled care and hygienic handling for mothers and newborns by skilled birth attendants (SBA) at delivery based on EmONC principles (v) early identification, provision of life saving first aid measures and rational referral for life threatening complications, i.e. antenatal hemorrhage, infections and severe hypertensive-renal disorders in pregnancy; (vi) focused postnatal care to prevent complications or identify any complications early by critically observing the mothers at least once at 6hrs, in 6 days, after 6 weeks and at six months (the four sixes), checking especially for post partum bleeding and or sepsis, starting life saving management and referring the mother and child promptly for further treatment; (vii) Post abortion care (PAC) to minimize mortality and prevent severe morbidity as a result of inevitable or incomplete abortions; and (viii) Prevention of mother to child transmission (PMTCT) of STI and HIV, and nutrition education and support for lactating mothers; (ix) Newborn care that aims to prevent the risk of death from hypothermia especially for the newborns with low birth weight and choking; baby friendly initiatives, i.e., prevention of pre-lacteal feeds, early initiation of breastfeeding and encouragement of exclusive breastfeeding ; identification of malformations, convulsive disorders or other obvious developmental anomalies and referral for treatment Family Planning and Women s Health (FP/WH) Family planning and women s health (FP/WH) is an initiative based on women s reproductive health rights (RHR). The objective of is to increase the percentage of women in their reproductive years using effective methods of contraception from the current 1.73% to 3% by 2010 and to 8% by Service elements are: (i) awareness raising on FP to empower women and men to practice conception by informed FP choices; (ii) provision of appropriate choices of effective FP methods to enable delay in initiation of child bearing for girls and birth spacing for women who have established child bearing to allow full recovery of health in between pregnancies and to minimize grand multi-parity (iii) create awareness and provide screening for and management of obstetric fistula; (iv) training in self palpation skills for masses in the breast and seeking examination or referral; (v) encouragement to regularly attend clinics for Pap smear, provider initiated counseling and testing (PICT) for HIV, (vii) promotion of tetanus toxoid (TT) vaccination for Women of Reproductive Age (WRA); and (iv) condom programming for protected sex and syndromic management of STI (SMSTI) and mass communiation to promote voluntary counseling and testing (VCT) Adolescent Sexual Reproductive Health Services (ASRHS) ASRHS will provide services for adolescents and young people to prevent sexually transmitted infections, adolescent pregnancies and HIV/AIDS. Youth friendly service provision and care will be adopted to encourage health seeking behavior among young people. The goal is to increase RH awareness and Reproductive Rights knowledge among the youth to 90% by Service elements include: (i) Gender and Sexuality education; (ii) ABC promotion; (iii) VCT/PICT; and (iv) SMSTI. 15

16 Men s Reproductive Health Services (MRHS) MRHS will promote safe sexual practices and raise awareness on reproductive organ diseases of men. The service elements are: (i) Promotion of equitable gender roles in family health care; (ii) Promotion of VCT/PICT; (iii) reduction of sexual partners and condom use; (iv) SMSTI; and (v) Awareness raising and referral for suspected prostate cancer and enlarged prostrate Integrated Essential Child Health Care (IECHC) Southern Sudan currently has the highest child mortality rate in the world. The mean IMR was estimate in the SSHHS 0f 2006 at 102/1,000 live births, while the CMR or under five mortality rate (U-5MR) was 135/1,000 live births. The rate of generalized acute malnutrition (GAM) is 33%, with only 21% mothers exclusively breastfeeding their children fox six months. The same survey showed that only 43% of all under fives were fully immunized. Integrated essential child health care (IECHC) is a term that incorporates the global integrated management of childhood diseases (IMCI), while approaching the child survival and development issues from a health perspective. It is an approach that is includes all the technical aspects of IMCI but emphasizes focus on the well child and disease prevention. The aim is to improve child survival and development. The objective of IECH in Southern Sudan is to reduce child mortality rate by 25% by the year The interventions to achieve these objectives are integrated in BPHS under the following specific service norms: Community Based Child Survival Program (CBCSP) This is a mix of community level actions that address the most common childhood illness by promoting preventive measures, recognizing signs of illness in children early and treating them safely while observing for danger signs and other reasons for referral to the PHCUs, PHCCs or hospitals for more technical assessment and appropriate treatment promptly. The program will deliver behavior change communication on nutrition, growth monitoring and prevention, home treatment of malaria, diarrhea and recognition and referral of pneumonia, through a network of community based providers trained in the competent use of simple algorithms to assess, classify (assign) and treat the ill children, while counseling mothers, fathers and other caregivers in child health seeking behavior. This will be carried out under the oversight of CHEWS. Community based child survival package will include but not be limited to (i) prevention and treatment of malaria, (ii) prevention and treatment of diarrhea, (iii) management of acute respiratory infection (ARI) and pneumonia, (iv) mass campaigns for immunization, (v) community based growth monitoring and promotion,(vi) home management of mild malnutrition, vitamin A supplementation and periodic mass treatment for worms, (vii) referral of children with severe malnutrition and complications or those with malnutrition not responding to appropriate community based rehabilitation to TFCs Expanded Program on Immunization (EPI) The program target is to raise access to routine immunization (as measured by DPT3 coverage) from the current less than 10% to 30% by 2008 and to 80% by 2011; however, all the coverage for all the other antigens will be monitored as well with the aim of attaining herd immunity that is 80% or more coverage by This will be attained through routine immunization of children daily in all PHCC, monthly immunization of children in PHCUs and other designated sites by mobile outreach teams, mass immunization on acceleration days and NIDs and mop up immunization activities. 16

17 Essential Nutrition Action (ENA) The target of ENA is to reduce severe malnutrition from its baseline levels by 30% at the end of 2009 and by 50% by This program is an initiative to primarily prevent malnutrition, but includes very specific measures for resuscitation and rehabilitation of children who are severely malnourished. The services include (i) the promotion of exclusive breast-feeding for at least the first 6 months of life and provision of complementary feeding with continued breastfeeding for at least 24 months, (ii) growth monitoring and promotion (iii) micronutrient supplementation and community based nutrition rehabilitation for children with mild to moderate malnutrition; (iv) provision of treatment and rehabilitation for children who get severe malnutrition, with complications at designated Theraputic Feeding Centers (TFCs) Home treatment of Malaria, Diarrhoea and Pneumonia In Southern Sudan, Malaria accounts for 20% to 40% of all consultations at outpatient departments and between one in every five (1/5) and one in every four (1/4) deaths. Deaths are especially common among children under the age of five years, pregnant women and people from areas where malaria transmission is seasonal. Diarrhea and other enteric infections are common in Southern Sudan because of poor sanitation and use of surface water or water from unprotected sources. As in all countries with high CMR, it is estimated that diarrhea associated deaths account for between one in five (1/5) to one in three (1/3) of childhood deaths. Reduction of the period of breast feeding and early introduction of weaning foods (before six months) that tend to set in with affluence significantly increase the diarrhea morbidity and the risks of deaths from severe dehydration change in infant feeding and weaning practices. Acute respiratory infection (ARI) is frequent in children in Southern Sudan. There is currently little or no accurate data on the frequency of occurrence of ARI, but on the average children get infected once every one or two months. The severe and dangerous form of ARI is acute lower respiratory tract infection (ALRI) or pneumonia. Like diarrhea, pneumonia is a common cause of childhood deaths in Southern Sudan especially in children under the age of five years. It is much more common in the colder highlands climates than in the warm lowlands. Pneumonia occurs more commonly in children that are weaned at an early age, or those that suffer from malnutrition as a result of complications of other infections such as malaria and the vaccine preventable disease. More over a large number of children will also suffer from pneumonia as a direct complication of measles and other vaccine preventable infections. Vitamin A deficiency also increases the risk of all the three infections pneumonia and the risk of dying from the vaccine preventable childhood infections. Another cause of pneumonia is keeping children in smoky places. Protein energy malnutrition (PEM) and micronutrient deficiency especially vitamin A and zinc, aggravate the severity of infections and increase the risks of deaths in childhood Management of endemic Common Endemic Diseases (MCED) The most common endemic communicable diseases in Southern Sudan are Malaria, diarrhea, enteric infections and worm infestations, acute respiratory infections (ARI) and tuberculosis (TB). Other common health problems are visual, especially infections such as trachoma and refractive errors and other eye problems among children. Southern Sudan also lies along the meningococcal belt of the African Continent and outbreaks tend to occur at the beginning of dry season. South Sudan is now exposed to the human immunodeficiency virus (HIV) infection and the acquired immune deficiency syndrome (AIDS) pandemic and all efforts need to be made to prevent the epidemic taking root in the country. 17

18 Malaria Malaria is transmitted throughout the year in the swampy lowlands. In all other areas incidence of Malaria increases during rainy or flooding seasons as well as in association with movement of populations with little immunity to endemic areas when outbreaks occur or the disease reaches epidemic proportion. Since malaria is among the top leading contributors to the burden of diseases, the Ministry has established a special Roll Back Malaria program within the Directorate of Preventive Health. The program has 8 set objectives that are integrated into the BPHS under the following service norms: Prevention The objective is: to increase population coverage with effective malaria prevention as part of an integrated vector control strategy that utilizes all approaches including long lasting insecticidal nets, indoor residual spraying and environmental management when and where most suitable and sustainable. The targets are: (i) Sixty per cent (60%) of children under the age of five sleep under LLITN, (ii) seventy (70%) of households have one or more LLITN, (ii) Sixty per cent (60%) of pregnant women sleep under LLITN, (iii) Eighty per cent (80%) of structures in target areas are sprayed with quality indoor residual spraying (IRS) The services are: (i) Mass distribution of LLITNS, (ii) distribution of LLTNS through ANC, immunization clinics and (iii) mass spraying of living structures Case management The objective is: to provide wide access to diagnosis and highly efficacious artemisinin-based combination therapy to all affected by malaria using a mix of approaches that include public and private health care providers, a trained and supervised commercial sector and community distribution. The targets: (i) Sixty per cent (60% ) of children under the age of five with fever receive ACT within 24 hours, (ii) Sixty per cent (60%) of patients with uncomplicated malaria attending health facilities receive correct diagnosis (iii) to identify signs of very severe disease timely, give pre-referral treatment (oral ACT for those who can swallow and retain, rectal Artesunate suppositories for those who cannot swallow or retain and anticonvulsant diazepam- for patients who have fits) and refer promptly in 90% of cases. The services are: (i) Use of algorithms for assessment, assignment and treatment of children under the age of five promptly with appropriate (ACT) at community- home management of malaria (HMM) within 24hrs, to minimize delay in initiation of treatment, (ii) early detection of sings of malaria prompt confirmation of diagnosis of malaria and treatment for older children and adults at PHCU/PHCC and (iii) recognition of danger signs of malaria, referral and prompt initiation of second line treatment with quinine Malaria in Pregnancy The objective is : To deliver a package consisting of ITN, IPT and effective treatment to pregnant women through comprehensive and focused antenatal care services involving all levels of health care including the communities. 18

19 The targets for M/E are: (i) Reach sixty per cent (60%) of all pregnant women with ANC services with 2 or more doses of intermittent preventive treatment (IPT), (ii) sixty per cent (60%) of expectant mothers sleep under LLTNs, The services include: (i) counseling of mothers to attend ANC and get at least two (2) doses of IPT, (ii) early detection of fever in pregnant mothers, test for malaria at PHCU/PHCC and provision of treatment with appropriate medicines, (iii) complementary distribution of IPT through community based maternal health workers or midwives and (iv) detection and treatment of anemia IEC, Social Mobilization and Advocacy The objectives is: To mobilize all sectors of society to promote malaria control and increase adoption of positive behavior, based on a comprehensive malaria communications strategy that includes all available media and communication channels. Targets for M/E are: (i) At least 80% of responsible members of families know the effects, signs and symptoms of malaria, importance of prompt and complete treatment with the effective artemisinin-based bases combination treatment (ACT),(ii) Eighty per cent (80%) of health service providers sensitize and advise their clients (patients) on malaria prevention, early detection and treatment of cases at each health service session. The services are: (i) Awareness creation on malaria and its effects, (ii) promotion of acquisition and on sleeping under LLITNs, ANC and IPT, use of simple algorithms for home management of mamlria for children under the age of five year by household health promoters (iii) compliance counseling for proper use of LLTNs Diarrhea, enteric infections and infestations In Southern Sudan, enteric infections are still common and cholera epidemics occur from time to time especially during the changes from dry to wet seasons and vice versa. During such periods dysentery caused by bacteria, amoeba or flagellate infections also tend to increase. The service elements for management of enteric infections include (i) raising community awareness on the causes of diarrhea and its prevention. Mothers are to be encouraged to continue with the healthy infant feeding and weaning practices, (ii) Training communities on safe use of potable water and promotion of hand washing before and after handling food, after toilet including after cleaning or handling children s feces; (iii) raising awareness on safe disposal of feces including those of children; (iv) promoting immunization especially against measles (v) and regular administration of vitamin A (every six months) for all children under the age of five; (vi) all parents and other people who care for children are to be taught to (a) recognize outbreaks of diarrhea early and immediately alert staff at PHCU or PHCC. Additional gastro enteric infection and infestation related services are regular deworming of children through periodic mass campaigns and school health programs; and health education of recognition of other enteric infections especially abdominal pain, progressive fever and generalized weakness, constipation or small loose stools that signify typhoid fever. Such are to be referred to PHCC for laboratory investigation, diagnosis, treatment with antibiotics and are to be reported to the payam and county health authorities. 19

20 Other services for prevention of diarrhea directed to communities are: (i) awareness raising and sensitization workshops for village development committees - participatory health and sanitation (PHAST) training for community health workers and maternal child health workers. Facilitation for practical identification of water points, their protection and discouragement of risky sanitary practices by identifying them and developing community based interventions. Emergency preparedness by identifying early warning signs for outbreaks of diarrhea and developing responses and reporting. Construction of demonstration toilets and protection of water sources in schools, market places and administration centers, and any other strategic places such as community gathering venues Acute Respiratory Infection (ARI) Older people with pneumonia must be referred promptly to the PHCU to start treatment with oral antibiotics immediately and further to PHCC for treatment with antibiotics injections and oxygen if respiratory failure sets in. Report cases of pneumonia accurately every week Tuberculosis Although, the exact burden of Tuberculosis in Southern Sudan remains unclear, it is a major cause of morbidity and mortality. The estimated incidence of new sputum smear positive TB cases is 101 per 100,000 Population and 228 per 100,000 Population for all TB forms. With an estimated population of 9.7 million people in 2007, this translates accordingly to 9,797 new sputum smear positive TB cases and 22,116 TB cases of all forms occurring every year. TB mortality is estimated at 65 per 100,000. This situation is likely to be worsened by the cropping HIV epidemic which from limited surveys is already standing at 1% to 7% in the general population with border towns close to some Sub-Saharan African Countries such as Uganda, Kenya, Ethiopia, Democratic Republic of Congo (DRC), Central African Republic having high prevalence rates compared to the interior of the Country. The HIV sero-prevalence among TB patients indicate that 11.2% of the TB patients are co-infected with HIV with higher prevalence been noted in Nzara (50% HIV prevalence among TB patients, Nimule (25% HIV prevalence among TB patients), Yei (14% HIV prevalence among TB patients) and Rumbek (10% HIV prevalence among TB patients). HIV fuels the prevalence of the TB epidemic by promoting the rapid progression of recent and latent mycobacterium tuberculosis infection into active disease, and increasing the rate of recurrent TB. TB in people living with HIV/AIDS pose a greater risk of increased transmission of tuberculosis in the community, on the other hand, TB has a profound effect on the course of HIV/AIDS infection because it accelerates the process of transit from asymptomatic HIV to AIDS Related Complex (ARC) or to overt AIDS. The overall goal of the TB program to contribute to the improvement of the quality of life of the people of Southern Sudan by reducing dramatically the burden of the TB in Southern Sudan in line with the Millennium Development Goals and Stop TB Partnership Targets The objectives are: (i) to expand the DOTS coverage to 100% by the end of 2013 without compromising the quality of case detection and treatment, integrating it into the BHSP, (ii) (ii) to raise the number of tuberculosis cases detected from 1,562 cases in 2005 to 7,000 smear positive cases by 2013 while maintaining cure rate at 85%, (iii) (iii) to prevent emergence of drug resistant tuberculosis and monitor TB resistant patterns in Southern Sudan and 20

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