End of Project Evaluation Report for Global Fund Grant for Strengthening Health Systems in South Sudan: Round 9 (SSD-910-G13-S)

Report Cover Image
Evaluation Plan:
2012-2016, South Sudan
Evaluation Type:
Final Project
Planned End Date:
07/2016
Completion Date:
10/2016
Status:
Completed
Management Response:
Yes
Evaluation Budget(US $):
60,000

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Title End of Project Evaluation Report for Global Fund Grant for Strengthening Health Systems in South Sudan: Round 9 (SSD-910-G13-S)
Atlas Project Number: 00064223
Evaluation Plan: 2012-2016, South Sudan
Evaluation Type: Final Project
Status: Completed
Completion Date: 10/2016
Planned End Date: 07/2016
Management Response: Yes
Focus Area:
  • 1. Poverty and MDG
  • 2. Others
Corporate Outcome and Output (UNDP Strategic Plan 2018-2021)
  • 1. Output 3.3. National institutions, systems, laws and policies strengthened for equitable, accountable and effective delivery of HIV and related services
SDG Goal
  • Goal 3. Ensure healthy lives and promote well-being for all at all ages
SDG Target
  • 3.3 By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases
Evaluation Budget(US $): 60,000
Source of Funding: Global Fund for Tuberculos HIV/AIDS and Malaria
Evaluation Expenditure(US $): 60,000
Joint Programme: No
Joint Evaluation: No
Evaluation Team members:
Name Title Email Nationality
Ajuoga Alwar Team Leader
Philip Deng Team Member
Ojara Benson David Team Member
GEF Evaluation: No
Key Stakeholders: Ministry of Heath, Ministry of Physical Planning and Infrastructure, Global Fund, Country Coordinating Mechanism (CCM), United Nations Fund for Population, United Nations Childrenâ??s Fun, World Health Organization
Countries: SOUTH SUDAN
Comments:

Completed evaluation

Lessons
Findings
1.

Chapter 4: Contribution to Results

This section provides an analysis of the finding as derived from review of the project proposal and grant agreement, the periodic and special reports and minutes of the various sub committees where they were relevant to the evaluation process. The evaluation focused on relevance of this project to the prevailing situation in the South Sudan Health sector at the time of proposal and during implementation (of UNDP’s and GFATM involvement and its approach); effectiveness (in contributing to the achievement of outcomes); efficiency (in delivering outputs) and the sustainability (of the outcomes).

4.1. Relevance Discussions with key informants overwhelmingly suggested that the Global Fund programme staff did consider priorities of health systems strengthening and were addressed to the best effort that the implementation environment allowed. Global Fund Round 9 recognized that the human and social indicators at the start of the project were dismal and as a programme, inventions have been integrated to the health needs and priorities of South Sudan through robust inclusive stakeholder consultations of the government, donors, civil society and beneficiaries.

The R9HSS followed a common strategic framework in complimenting MoH priorities among which was the Health facility infrastructure development as indicated in the health policy3 . The grant also complimented UNDAF4outcome 3 on Social and human development which recommended that key service delivery systems are in place to lay the ground the ground work for increased demand. The grant was implemented through MoH structure from national, state and county levels.


Tag: Relevance Global Fund Health Sector Country Government Civil Societies and NGOs

2.

4.2. Effectiveness

In deed the evaluation team confirmed that nearly all the proposed activities were implemented. Both the programme staff and evaluation team agreed on the aspects that were either incomplete or where workmanship did not meet expected standards. The evaluation team also assessed functionality and where it was inadequate; the causes for inadequacy were identified.

Nearly all intended outputs of maternities, Blood Banks, laboratories, ANCs, M&E offices and teaching institutions were completed and handed over to the ministry of health however some have not been fully completed and handed over to the government especially phase 2 facilities.

 


Tag: Effectiveness Health Sector HIV / AIDS Institutional Strengthening Vulnerable

3.

4.3. Performance on outcome indicators

Table 4 presents the outcomes that the evaluation team could establish from the available documents and from the discussions with staff in the facilities visited. It may not be comprehensive but adequately indicative.

 


Tag: Effectiveness Impact Health Sector HIV / AIDS Value Chain Capacity Building

4.

4.4. Efficiency

There was evidence that management responsibilities were shared between the UNDP project management unit and the CCM and very clearly the CCM played the stewardship role of the MoH competently5 . There was evidence of joint decisions making where derogation for reprograming of activities or financing was necessary based on country situation. Whereas the Global Fund governance structure clearly reflects the centrality that Government should be in the lead, the evaluation team was unable to fully establish if the CCM was adequately resources for its oversight functions.

 


Tag: Efficiency Global Fund Health Sector Country Government UNDP Management

5.

4.3. Sustainability

The CCM is proactive and continues to provide leadership to the programme. There was evidence that the TB and HIV programmes are now fully owned by the government as well as the running of the constructed facilities like maternity Wards and ANCs. Capacity has been built for M&E at the national, state and county levels through trainings supported by the grant. Training on pharmaceutical management led to progressive improvement in supply chain management for most essential health supplies. There was evidence that training institutions were supported and benefited from teaching aids and qualified tutors. There was mutual complementarity between GF projects and other funding mechanisms example the Health Pool Fund (HPF), Management Sciences for Health (MSH) and United States Aid for International Development (USAID).

Capacity has not been adequately built for preventive maintenance of equipment. There were gap in human resource capacities, important cadres such as Biomedical Engineers and technicians are absent. There was no clear exit strategy for the project. There were foundational issues in the selection and admission of students in mid-level medical training institutions.


Tag: Sustainability Health Sector Monitoring and Evaluation Project and Programme management Bilateral partners Institutional Strengthening Technical Support

6.

4.4. Budget utilization

Table 5 presents the budget utilization by results, the analysis is not complete but as can be observed most areas show close to 80 percent utilization. The low use areas are technical and management assistance at 63.2 per cent and communication material at 56.7 per cent and health products. The remnant fund can still be absorbed during the period of no cost extension give that the prolonged period of conflict obstructed or delayed some activities still in infrastructure, health products and health equipment. The remnant resources should be used for technical support in ensuring defective constructions, equipment installation and preventive maintenance is instituted.


Tag: Relevance Health Sector Human and Financial resources Procurement Post Conflict Technical Support

7.

This chapter describes the activities implemented and related actions or interventions through the R9HSS financing. The intended outcomes of these actions included but were not limited to increase the capabilities of the South Sudan Health sector to train the health work force, that is service providers and support staff; to establish systems to work towards the health commodity security by improving acquisition warehousing and supply chain logistics; establish the health information system to ensure future planning was evidence based; and to improve access to quality services.


Tag: Coherence Effectiveness Relevance Health Sector Value Chain Capacity Building

8.

3.1. Capacity building for HSS including health workforce
This intervention was aimed at improving the number of qualified human resources and the quality of the service through the strengthening of the National training system already in place. It was observed that rehabilitation and renovation works have been completed in three teaching institutions namely - Malakal Health Institute, Juba Midwifery and Nursing Schools and Wau Midwifery School. Construction of dormitories for students at Juba Midwifery and Nursing school has increased enrolment to 180 students.
“Before the dormitory was constructed students were coming late to school. When it rain they don’t come. Now we have this dormitory, punctuality has improved”- Principal, Juba Midwifery and Nursing School.


Tag: Effectiveness Relevance Health Sector Capacity Building Institutional Strengthening

9.

In general, the contracts of several tutors that were recruited by GF expired at the end of the HSS grant in September 2015 and were not renewed. Some of the tutors, however, were hired by other programmes and continued to support the training (for example, the tutor in Wau who was now employed by International Medical Corps –IMC- with funding from Health Pooled Funds). A number of challenges were identified in recruitment of national tutors. In several places there were no adequate affordable housing, while English was the requisite medium of instruction, most national tutors were not proficient in English.
During the visit to Malakal, the evaluation team noted that the Malakal Health Institute was affected by the conflict, all the furniture was looted and facility is non-functional. The situation in Malakal was difficult to evaluate, there were no respondents since there were neither students nor Tutors. It was observed that the location was not appropriate; it was very far from the hospital and too close to the airport and there was no perimeter fence for the institute.


Tag: Challenges Effectiveness Relevance Health Sector Human and Financial resources

10.

3.2. Strengthening of the Drug Supply Management Renovation of the Central Medical Store was completed and capacity has expanded to accommodate 2000 different types of drugs. There is on-going construction of another warehouse at the river side to further increase the storage capacity especially for temperature labile products. It was noted that power fluctuation was affecting the fridges and it is necessary that a solar system is installed with automatic switch. It was also observed that warehouses were being managed entirely by UNDP staff and capacity transfer for sustainability was absent. The constructions of incinerators (6) was completed but were not commissioned at the time of the evaluation. From discussions with the PR, it was noted that there are concrete plans to complete the commissioning by the end of March 2016. There was evidence that the PR provided technical assistance on pharmaceutical management to build capacity. Both programme and government staffs were trained, there were regular scheduled supervisory field visit and these were accomplished well up to 2014 albeit with some difficulties in 2014 and 2015. These are being resumed now.


Tag: Effectiveness Health Sector Value Chain Institutional Strengthening

11.

3.3. Strengthen Health Information System The R9HSS was intended to provide technical assistance for comprehensive health management information system, finalize the M&E manual, print and disseminate data collection registers and strengthen M&E offices at the State level. It was noted that the PR recruited 4 international UNVs and 2 national M&E staff to streamline M&E activities and to provide overall technical assistance.


Tag: Effectiveness Efficiency Relevance Health Sector Monitoring and Evaluation Policies & Procedures Strategic Positioning Institutional Strengthening

12.

3.4. HSS Service Delivery
The focus of the grant was to renovate laboratories at state hospital level, procure equipment, test kits and supplies for laboratories and establish, equip and operate State Blood Banks. It was observed that the PR constructed 4 laboratory class rooms at Juba Health Science Institute. This has increased enrolment from 249 to 400 students. It was however noted that the approved design and furnishings by the MoH and CCM were not to expected standard for teaching institution. Notably, there was no storage cabinet for equipment, reagents, apparatus, water for washing and staining, central working station, room for lab technician office and fire extinguisher. These are fundamental flaws this was because there was no national design for health training school laboratories to ensure that constructions are compliant to national standards.


Tag: Effectiveness Relevance Health Sector Institutional Strengthening Technical Support

Recommendations
1

Recommendations to UNDP/GF for Programme design and planning

  •  There should be proper coordination of the construction of infrastructure and the delivery of furniture and equipment.
  •  There should be a phase of this project that will address issues of sustainability before closure of the project.
  •  The period of defect liability should only start when the construction works are fully satisfactorily completed and the furniture and equipment installed and functional.
  •  The PR should recognize the mandate of the CCM which includes; coordination of development and submission of national request for funding, oversight of implementation of the approved grant, reprogramming and ensuring linkages and consistency between Global Fund grants and other national health and development programmes.
  •  There is need to have nationals working alongside the internationals GF staff for the building their capacity in the long term this is especially in training facilities and with biomedical technology resource persons.
2

Once health facilities are completed and equipped, they should be immediately handed over to the Ministry of Health for use. 

1. Recommendation:

Recommendations to UNDP/GF for Programme design and planning

  •  There should be proper coordination of the construction of infrastructure and the delivery of furniture and equipment.
  •  There should be a phase of this project that will address issues of sustainability before closure of the project.
  •  The period of defect liability should only start when the construction works are fully satisfactorily completed and the furniture and equipment installed and functional.
  •  The PR should recognize the mandate of the CCM which includes; coordination of development and submission of national request for funding, oversight of implementation of the approved grant, reprogramming and ensuring linkages and consistency between Global Fund grants and other national health and development programmes.
  •  There is need to have nationals working alongside the internationals GF staff for the building their capacity in the long term this is especially in training facilities and with biomedical technology resource persons.
Management Response: [Added: 2016/10/16] [Last Updated: 2021/02/22]

UNDP will work with the Ministry of Health to provide technical assistance in the development of the standards designs for health facilities and specification for medical equipment.UNDP will work with the Ministry of Health to provide technical assistance in the development of the standards designs for health facilities and specification for medical equipment.

Key Actions:

Key Action Responsible DueDate Status Comments Documents
Standards and specification that exist will be identified and reviewed by the directorates. New standards will be developed and disseminated for consensus with end users. The new and revised standards will then be shared with procurement teams to guide the development of ToRs and bid documents.
[Added: 2016/10/16] [Last Updated: 2017/06/13]
Ministry of Health with support from UNCP, Common Country Coordination Mechanism (CCM) 2017/02 Completed All Global Fund procurements are now guided by standards approved by the directorates. History
2. Recommendation:

Once health facilities are completed and equipped, they should be immediately handed over to the Ministry of Health for use. 

Management Response: [Added: 2016/10/16] [Last Updated: 2021/02/22]

UN will ensure timely handover of all completed facilities to the Ministry of Health

Key Actions:

Key Action Responsible DueDate Status Comments Documents
Upon handover of facilities, UNDP will follow up with the Ministry of Health to facilitate use of the completed health facilities
[Added: 2016/10/16] [Last Updated: 2018/08/22]
UNDP, Ministry of Health 2017/12 Completed UNDP Global Fund follows and and monitor utilisation of assets handed over to the government. Attached is a narrative of that process bein implemented as a risk mitigaiton measure History

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