THIRD QUARTERLY REPORT

WHO SOUTH SUDAN REPORT THIRD QUARTERLY REPORT JULY SEPTEMBER, 2012 The UN staff of South Sudan during the signing of the United Nations Development Assistance Frame work (UNDAF). WHO was one of the UN agencies that signed the UNDAF agreement on behalf of the health implementing partners. 9/30/2012 WHO South Sudan third quarterly report, 2012 This report summarizes achievements, challenges and the way forward for the WHO South Sudan activities covering the period July September 2012 and focuses on 8 programme areas.

Table of Contents 1.0 Background 1.1 The general context in South Sudan 1.2 Current situation in the states 2.0 WHO major achievements in the 3 rd quarter (July - September), challenges and the way forward. 2.1 Emergencies and Humanitarian Action (EHA) 2.2 Communicable Disease Surveillance and Response (CSR) 2.3 Polio Eradication 2.4 Guinea worm 2.5 Tuberculosis 2.6 Health Systems Development 2.7 APOC 2.8 Health promotion, advocacy and communication 3.0 Conclusions Page 1

3 rd QUARTER REPORT, JULY SEPTEMBER, 2012 W H O S O U T H S U D A N Q U A R T E R L Y R E P O R T, 2 0 1 2 1.0 Background 1.1 The general context in the Republic of South Sudan. The humanitarian situation in South Sudan was somewhat stable during this reporting period. Less aerial bombardments were reported this quarter compared to the previous 2 quarters, January to June 2012. However the influxes of refugees from South Kordofan and the Blue Nile as well as the high numbers of returnees from Sudan continued this quarter and large internal displaced people due tribal clashes and floods Inter-tribal clashes continued in some states between the Rebel Militia Groups (RMGs) and the Sudan People s Liberation Army (SPLA) also continued happening in Jonglei state. This resulted in displacement of people from their original homes thus an increased for health and humanitarian support. The organization also increased her visibility and technical support in Maban County, one of the most vulnerable counties in the Upper Nile state. This was done by deploying a technical officer to support all health relation operations and partners operating in the county. As a result there has been increased visibility in the area and support being better provided for now. To ensure that displaced people receiving assistance during this quarter, WHO maintained its support by providing leadership to the health partners (UN agencies, NGOs, Civil societies and MOH) in emergency and crisis preparedness at the national and sub national levels. Technical and financial support was provided to the Government of the RSS and the states to implement key focused life saving health interventions while advocating for more attention and funding. Together with the MoH/RSS, the organization participated in several Joint health Assessments in states affected by different emergencies. 1.2 The Current situation in the states The South Sudan humanitarian operation remains precarious, complex, challenging and expensive. Currently, over 60% of the country is cut off from accessing humanitarian assistance and delivery of emergency response mainly caused due to flooding. This has worsened the very already fragile health systems (HR, Drug Supply management, leadership at all level, unpaid salary, etc). In South Sudan, displacement, floods, conflicts and ethic related violence, emergency returnees, the refugee crisis and communicable disease outbreaks continue to impact negatively on the humanitarian response. Since the start of 2012 to the end of this reporting quarter, over 208 incidents of conflict were reported in nine states. Jonglei was the most affected (38 incidents) with 1303 fatalities and 167,931 persons displaced as a result of the same. Over 110,000 other people remain displaced in Twic County and Agok areas. To support the ministry of health respond to the needs of those displaced, WHO Page 2

in collaboration with other partners devised contingency plans to support the possible return of 30,000 people into the Abyei Peace Comprehensive Area (PCA). This was however unlikely to take immediate affect following heavy rains which are anticipated to last until the end of November 2012. During this quarter, the United Nations Country Team (UNCT) signed the United Nations Development Assistance Framework agreement (UNDAF) with the Government of the Republic of South Sudan. WHO signed to support the government attain UNDAF outcome 3 of ensuring that key basic service delivery systems are in place, laying the groundwork for increased demand. This outcome will focus on health and maternal mortality among others. WHO will work closely with the government to compliments its efforts in managing and delivering an essential package of health, nutrition and HIV services and to reduce maternal and child health. This will be done by helping the government construct, expand and reinforce the pharmaceutical and vaccine supply chains, expand Health Information Management Systems at the state level among others Partnership is one way of ensuring successful programming for which WHO strongly advocates for. During this quarter, the organization participated in a number of partnerships among them the World Population Day. The Head of the WHO South Sudan Office, Dr. Abdi Den Mohamed at the time also Acting Humanitarian Coordinator (HC/a.i) delivered a message on behalf of the Secretary General on World Population Day 2012. The speech was read to the government ministers, diplomats and other dignitaries. Picture below: The WHO Head of Office, also Acing Humanitarian Coordinator (HC/a.i) at the time delivering a speech on behalf of the Secretary General, Ban Ki Moon to Government ministers, diplomats and other guests during the World Population Day celebrations held on July 26, 2012 at Nyakuron cultural centre, South Sudan Picture below: The WHO Head of Office Dr. Abdi Aden Mohamed signing the UNDAF agreement, next to him is the Vice- President of the Republic of South Sudan Dr. Riek Manchar. Behind are other heads of UN agencies of the Republic of South Sudan. Page 1

2.0 WHO's Major Achievements in The 3 rd quarter. (July to September) 2012 2.1 Emergency Humanitarian Action (EHA) The strategic objective of the EHA program is to reduce health consequences of emergencies, disasters, crisis, and conflicts and to minimize their social and economic impacts. During this quarter, 39 of the 79 counties were affected by floods. Although an estimated 245,902 persons were affected by the floods, there was minimal displacement. Jonglei state was the most affected with 194,536 people affected from 10 of the 11 counties. In addition to affecting thousands of people, the floods also affected humanitarian accessibility in high risk areas, and transportation of regular and emergency medical supplies to target health facilities. Since the start of the year, an estimated 124,982 persons have been reported to have returned to South Sudan (IOM 2012), these continue to receive integrated and re-insertion packages at their final points of destination. Another estimated 14,134 are still reported to be stranded in Renk (Mina, Abyouk and Payer sites), 3,896 others in two ways stations of Juba and National Teacher Training Institute (NTTI). The continued influx of Sudanese refugees in to South Sudan continues to strain humanitarian actors as over 170,000 refugees are reported to have fled the fighting and have reportedly entered Yida and Maban in Unity and Upper Nile states respectively. These face malnutrition, and very poor water and sanitation conditions, which posses a public health risk to both the refugees and host community.. In August 2012, the Ministry of Health declared hepatitis E virus outbreak in Maban County a disease associated with poor sanitation During the quarter, WHO continued to support the Ministry of health at both the national and sub national level in the following priority areas: 1. Strategically prepositioned emergency supplies and life saving drugs to high risk and other key spots in the hard to reach areas experiencing acute emergencies 2. Ensured that populations of humanitarian concern accessed emergency health services through restoring basic Primary Health Care (PHC) services and establishing mobile clinics. 3. Carried out health tracking and communicable disease surveillance in areas of concern, while taking appropriate action by detecting, responding and containing any potential outbreaks. 4. Strengthened the capacity of the state and county health authorities by providing leadership in coordination and delivery of critical health services. 5. Ensured that the Health Cluster support at central level and at state level was heightened. 2.1.0 Emergency Health Coordination In this quarter, WHO maintained its support and provided leadership to health partners (UN agencies, NGOs, Civil societies and MOH) in emergency and crisis preparedness. This support was focused at the national and sub national levels. Refresher trainings and orientation on emergency and preparedness committees tasked with coordination of emergency responses were also conducted at all levels. For instance in Malakal, WHO supported the training of the coordination task force for the flood responses and the refugee crisis in Maban County. As a result the Page 1

frequency of meetings for committee member s increased and key issues and challenges faced between partners during emergency response in Upper Nile state were frequently discussed. In addition, the programme also supported the taskforce to conduct support supervision visits to Nasir, Renk, Maban, Longecuk counties to strengthen the delivery of emergency health services in the affected areas. WHO also continued to play a role of technical advisory to partners. In this role, WHO undertook the secretariat function of coordinating meetings/forums of health actors, and supported the ministry of health with organizing weekly and monthly coordination forums/technical working groups to strengthen coordination mechanisms at the national and central level. This role was more prominent during the response to the conflict related displacement in Unity and Jonglei, Hepatitis E outbreak in Maban refugee camp, Anthrax outbreak in Wau. Other task forces that WHO has supported and functionalized are; the Ebola task force, and the national Flood response task force resulting in the coordination of over 23 flood responses across the ten states. A total of 33 health cluster meetings were supported across the ten states. Each state held regular monthly health cluster meeting and the same done at the national level. 2.1.1 Emergency Health and Needs Assessment During this reporting period, WHO supported the health emergency coordination mechanisms at the state and central levels. This greatly contributed to the improvement of the response time. A series of rapid and interagency health assessments were conducted for which WHO participated in all the ten states. As a result, the identified health gaps were responded to promptly and strategies to effectively respond to health crisis. This minimized the impacts of the emergencies reported. The organization also supported and participated in the assessments listed in the table below. The programme also conducted support supervision visits to the states of Western Equatoria State, Jonglei, Unity, Upper Nile, Lakes, Western Bahr el Ghazal, Eastern Equatoria State, and Warrap. The visits were meant to follow-up on emergency preparedness and response activities with emphasis on improving the quality of responses by the state actors. The program team also visited hot spots of Tumbura, Longecuk, Nasir, Koc, Tonj East, Agok, Maban, Yida, Renk, Atar, New Fangak, Turalei and Yirol Counties. 2.1.2 Technical support in emergencies During the third quarter, WHO in partnership with the Ministry of Health (MoH) Republic of South Sudan supported the implementation of the much needed health services in counties affected by emergencies. The support provided help to address the health needs for returnees, refugees and the vulnerable population. In collaboration with UNHCR and Page 1

the county health departments in Maban county, WHO deployed an epidemiologist to support the outbreak response for the Hepatitis E. Key of the activities that were strengthened following the deployment include; the establishment of an Early Warning and Response Network (EWARN) system in the host community, training of health promoters and community health workers on case management and detection of cholera and hepatitis E and strengthening of coordination of all health actors in the county. WHO STAFF AND IMC STAFF SIGN AWAY BILL FOR DRUGS THAT WHO DONATED TO IMC TO SUPPORT REFUGEES IN SOUTH SUDAN With the technical assistance offered by the technical officer deployed the county, the program enhanced the capacity of health workers to improve the quality of health services in Maban County. In addition, the program supported the MOH-emergency preparedness Unit to deploy extra emergency officers in the area of Maban during the acute phase of the epidemic and as such a number of assessments were conducted in the areas of WASH, Expanded Program on Immunization health promotion and disease surveillance among others. Following the increased Rebel Militia Group activities in Unity state, WHO supported the SMOH to deploy a surgeon to Bentiu Hospital for a period of three months and an additional 10 medical officers and nurses were swiftly deployed in Bentiu hospital, Unity to provide surge support following increased numbers of causalities admitted in the hospital. As a result, a total of 323 patients were treated for gunshot wounds and minor injuries. This surge capacity minimized the need for referrals (usually to Juba Teaching Hospital) and prevented unnecessary deaths from delayed treatment as injuries were successfully managed. To reinforce the hospitals capacity to respond to surgical emergencies and mass casualties, WHO procured surgical, anesthetic and blood transfusion kits. These kept the hospitals with essential and critical life saving supplies to promptly response to mass casualties In response to the floods in Nyirol County, WHO deployed a technical officer to support the response at county level for a month and improve access of health care services to the affected population. Communicable disease surveillance and coordination of the referrals of the critically ill was strengthened and as such lives were saved, Management of common illnesses was well implemented and a total of 2,340 cases were treated for a number of diseases during the response period. 2.1.3 Strengthening Local Capacities for response and emergency preparedness In this reporting period, WHO supported the MOH to conduct a number of training activities aimed at strengthening the capacity of a critical health work force involved in responding to emergencies. Being a country that has just emerged from war, health workers here require skills in emergency management to enable them respond appropriately and timely to health emergencies at the state level. With support from CERF, USAID and ECHO, the programme conducted 11 trainings in six high risk emergency states. In three states, trainings of Page 2

health workers and community opinion leaders on case management of suspected viral hemorrhagic fever was carried out in eight counties bordering with Ugandan and Congo as a preparatory measure to any potential outbreak. As a result, participants developed preparedness work plans and emergency budgets to support disease outbreak and risk communication in their counties. Four other trainings focused on the management of Childhood illnesses in emergencies. A total of 335 health workers benefited from the various trainings. It s hoped that the trainees will effectively manage common illnesses in resource limited settings. with emergency supplies. This role comes as the WHO/EHAs mandate to strengthen emergency preparedness and enable states urgently respond to the critical needs of vulnerable populations. The availability of supplies was key during the initial and acute phases of the emergencies that were reported in the states. 2.1.4 Filling Critical Gaps: Effective Emergency Preparedness and Timely Response One of WHO s core functions in humanitarian emergencies is to fill critical gaps. In order to reduce the response time in the event of health emergency and outbreaks, huge consignments of interagency health kits, cholera and meningitis kits, laboratory and medical supplies were pre-positioned in all WHO state offices, done in collaboration with the SMOH. The prepositioning was done periodically based on information received from the field. In addition to regular prepositioning, the program also responded to a number of emergencies namely; Floods, displacement due to conflict, mass causality trauma management, drug shortages in hard to reach areas and the upsurge of Acute Watery Diarrhea in key states. Twelve kits were distributed to Warrap, Upper Nile, and Northern Bahr el Ghazal states among others. Of the twelve kits three were Diarrhea kits in response to the AWD cases reported in Maban County, population hosting over 105,000 refugees. As part of the core pipeline management, WHO maintained its role as core pipeline manager for the health cluster and supported the SMOH and other health actors WHO also supported the returnee emergency response in the states of Warrap, Unity, Malakal, Northern Bahr el Ghazal, Jonglei and Western Bahr el Ghazal with emergency supplies to manage common illnesses in the transit sites and areas of high returns. In order to extend support for the expansion of available emergency basic services in refugee settings and in the IDP camps, WHO supported partners in the states with diarrhea kits, trauma kits and inters agency kits. These were given to WES, Warrap and Northern Bahr el Ghazal states. The kits supplied were very critical in the management of the common illnesses among the displaced populations and was enough to serve 45,000 people. In response to the health and needs assessment in Panthoi Village in Kuajok Warrap state, WHO supported and initiated a mobile clinic to provide emergency health services and Epidemic Preparedness services to the stranded returnees. Further to this, following a rapid emergency Inter-Agency assessment at the return site at Page 3

Mayen Gumel in Kuajok, the program through the MOH re-established and re-opened a Primary Health Care Unit which serves returnees (14,501) at the site and scaled up nutritional services for the returnees. In response to floods in Kuach Payam,WHO supported the Primary Health Care Unit and the affected population with 10 basic unit kits of anti malaria drugs, strengthened communicable disease surveillance and coordinated with the nutrition cluster to establish nutritional services in the payam for the affected people. 2.1.5 Provision of Health Services in Return Areas, refugee settings and Internally Displaced Persons. During the quarter there were marked improvements in the security situation in the border states. This resulted in, population movement to their homes and villages. This however made it difficult for the returnees to, access good quality health care services as many health facilities in the return areas had long been abandoned and are non-functional. As a follow up, WHO provided technical and logistic support to the County Health Teams to conduct joint and integrated technical support supervision to health facilities in an attempt to improve the delivery of health care services in the states. In the areas of Maban and Yida, where many refugees are reported to have settled, the delivery of quality health services was strained as the health facilities in these areas are already constrained in many ways. To address some of these challenges WHO/EHA worked with the State health teams to develop strategies for providing health services in this area. In Awiel, the programs supported the state teams to conduct mobile clinics in Apada (flood response) and outreaches, as a result a total of 1609 people were treated. During the acute phase of the emergency in Maban County, WHO supported IMC to initiate a static clinic in the Gendrassa camp. A total of 8,902 refugees and host comminute were treated at this health post. In response to the detoriating health state of the over 3000 returnees in the National Training Teachers Institute, WHO in collaboration with the SMOH of CES swiftly deployed health workers and provided drug kits to restore health services at the center. As a result 737 people were treated for different diseases. In Renk, an estimated 14,000 returnees remain stranded in transit camps awaiting transportation to their final destinations. WHO supported Med air with emergency drugs to manage the static clinics in the transit points, as a result 17,764 patients were registered during consultations to have accessed emergency health services and the health posts. To sustain continuity of health services among the refugee populations in Lasu and Ngorom, ACROSS benefited from the core pipeline supported by WHO through emergency stock. This resulted in the treatment of 11,621 returnees and refugees for common illnesses. At the transit point in Juba a total of 12, 655, returnees from Khartoum and Israel were treated and received emergency health services provided by IMC clinic and supported by WHO. 2.1.6 Resource Mobilization In collaboration with other members of the health cluster, WHO/EHA led the WHO s participation in the development and review of the mid-year review of the 2012 UN Humanitarian work plan. The organization also supported health partners to develop health cluster strategy for 2013. A total of 34 projects were reviewed and 31 recommended for the inclusion in to the Consolidated Appeal Page 4

Process 2013. The total budget is estimated at 91,291,042. The cluster will focus on three cluster objectives namely; maintain existing health service delivery by providing basic health packages and emergency referral services, strengthen emergency preparedness including trauma management and respond to health related emergencies, including control of the spread of communicable diseases. During this reporting period, WHO also submitted a proposal to the Spanish government worth 630,000 US dollars to support emergency health services. 2.1.7 Challenges 1. The operating environment in south Sudan is one of the most expensive and difficult in the world, with about 60% of the country being inaccessible. This has increased the delivery costs for emergency health response and humanitarian assistance. 2. The security concern especially at the Border States remained fragile. This impacted negatively on emergency and humanitarian responses. 2.1.9 Best practices and lessons learnt Mainstreaming of emergency activities into all programmes of WHO has resulted into an integrated and joint response approach to health emergencies. This is instrumental to the success achieved by WHO in effectively and timely responding to all health emergencies experienced during the year. Partnership with sister UN agencies and NGOs has resulted in better understanding of the mandate of WHO and in the technical capacity and comparative advantage of health cluster members which in turn facilitates better information sharing and effective coordination. Within the programme rotation of staff around the offices and other parts of the country to support specific tasks has not only expanded coverage of the supported activities but also improved the experience and the technical capacity of our staff to support emergencies. 2.2. Communicable Disease Surveillance and Response (CSR) The weekly Epidemic Preparedness and Response (EP&R) meetings regularly took place in Juba this quarter with increased participation of health officers and health cluster partners. The meeting were chaired by the Ministry of Health, RSS while WHO provided secretariat services. The EPR meetings is a forum that brings together health officers and cluster partners involved emergency response to review weekly surveillance data; discuss weekly alerts reported across the country; and provide the necessary technical advice and support to surveillance teams and health partners on outbreak verification and response. Regularly monthly health cluster meetings were also organized in all the states and some high risk counties like Renk, Maban and Agok. 2.2.0 Training and Capacity building Strengthening knowledge and skills among first line health care workers, surveillance officers, public health officers and other health managers is one of WHO s key mandates. Integrated Disease Surveillance and Response (IDSR) was one of the priority areas for WHO supporting this quarter. This was done in collaboration with health authorities and partners. Health workers and other health cadres requires regular refresher trainings to upgrade their knowledge and skills to enable them carry out case management, laboratory diagnosis, reporting, investigating and respond to outbreaks or other health related emergencies. As part of the recommendation by the mid-term evaluation team in 2011, the Page 5

training curriculum for integrated disease surveillance was revised and the duration of the IDSR training increased to five days. During this reporting period, a total of twenty (20) different trainings were conducted across the country, namely; 1. Four (4) Integrated Disease Surveillance trainings and response were conducted in Western Equatorial State (WES) and Eastern Equatoria State (EES). Those trained included; health care workers, polio field supervisors and field assistants, EPI managers, county medical officers of health, surveillance officers and public health officers. One training targeting participants from hospitals and Primary Health Care Centers (PHCC) in Central Equatoria State (CES) while the other 3 targeted polio staff, EPI managers, county medical officers of health and county surveillance officers from CES.WES and EES., In total, 149 participants benefited from these trainings in the three states. The trainings aimed at reorienting health workers, public health officers and managers on how to integrate disease surveillance system, provide new knowledge and skills needed to improve outbreak investigation, disease surveillance, reporting of early warning signals of impending outbreaks and initiate effective and timely response. After the training participants were provided with IDSR training package and technical guidelines for future reference. 2. Training was also conducted on malaria sentinel surveillance and case management in Wau. These targeted health workers from the greater Bahr el Ghazal region (Lakes, Western Bahr el Ghazal (WBGS), Northern Bahr el Ghazal state (NBGS) and Warrap states. A total of 28 health workers, states malaria focal persons (malaria coordinators) and Monitoring and Evaluation officers participated the training. The training was held with the objective of building the capacity of health workers in selected malaria sentinel sites in the four states to management and diagnoses malaria cases and collects accurate malaria data to enable accurate and proper monitoring of malaria trend across the county. 3. Five (5) refresher trainings on effective influenza surveillance including data collection, early detection, investigation and confirmation of outbreaks, routine analysis and rapid response to influenza like illnesses were conducted in 5 states of WES, Upper Nile, CES, Lakes and Warrap.One hundred and eighty eight (188) health care workers from referral centers were trained. 4. Nine (9) refresher trainings on Ebola preparedness and response trainings were conducted in three states bordering with Uganda and DR Congo (EES, CES and WES). The counties bordering with Uganda and DR Congo that benefited from the training include; Ikotos and Magwi/Nimule in EES; Morobo, Yei, Kajo-keji and Juba in CES; and Yambio, Maridi and Nzara in WES. A total of 316 primary health care workers, public health officers, health promoters, school teachers and some key community leaders gained from the training. The objective of the training was to sensitize health workers and others cadres on Ebola hemorrhagic fever surveillance, case management, infection control given that two outbreaks were confirmed in Uganda and DR Congo. 2.2.1 Surveillance and Epidemic Response a) Outbreaks Investigation: A total of one hundred ninety nine (199) outbreak rumors/alerts were reported and verified by state rapid response teams during this period. Over 70% of these alerts were Page 6

measles, followed by acute watery diarrhea. Five viral hemorrhagic fever alerts were reported this quarter from Yambio, Bor, Kajokeji, Yei and Juba, all investigated on time. They were all false alert. Of the alerts, only two measles outbreaks in Kapoeta East and Yambio Counties, one hepatitis E virus outbreak in Maban and one kala azar outbreak in Koch county were confirmed to be true in the past three months, with all others being false alarm. Over 70% of all outbreak alerts were investigated within three days of notification. Other rumors investigated included ILI, malaria deaths, unknown illnesses, AJS and others. Member of State Rapid Response Team in Jonglei state investigating suspected VHF in Bor Hospital. b) Laboratory Specimen: A total of 170 clinical specimens (serum/blood, stool and CSF) were collected and analyzed at the reference laboratories in Juba (for measles), Centre for Disease Centre Kenya Medical Research Institute (KEMRI) for AJS/yellow fever and AMREF-Nairobi (for cholera and meningitis). Of these specimens, 43 serum/blood samples tested positive for measles (16), AJS (Hepatitis E) and three for Shigellosis, while the rest were negative for the suspected epidemic prone diseases (measles, cholera, meningitis, yellow fever, hepatitis E and others). Eight blood/serum samples were not analyzed for measles confirmation due to inappropriate collection and inadequacy quality. Refer to table 1 for details of laboratory specimens. WHO and MoH-RSS succeeded to establish measles laboratory service in Juba Teaching Hospital, therefore all measles and rubella tests were carried out in Juba Teaching Hospital this quarter. As a result, the lead time to complete the measles and rubella test was 24 hours upon receiving the specimen in Juba. The Ministry of Health appointed an officer to be responsible for all laboratory issues related to epidemic prone diseases and she will manage the laboratory data at Juba level. c) Health Facility Reporting Performance: The number of health facilities that submitted timely and complete weekly surveillance reports slightly increased this period as compared to the same period in 2011 and 2010. In the third quarter, the average completeness rate by reporting health facilities was 51% as compared to 48% in the previous quarter. Nonetheless, some states made remarkable improvements in the timeliness and completeness of reporting this reporting period as compared to the previous quarters or years, with the most notable being in Upper Nile state which maintained over 50% timeless and completeness. At the same time, the number of priority facilities (hospitals and PHCCs) reporting increased in the 3rd quarter of this year. In Page 7

Maban and Yida refugee camps, the reporting performance from health facilities serving the refugees and surrounding host communities remained high although some facilities serving host communities failed to regularly report. 2.2.2 Disease specific surveillance reports a) Acute Watery Diahorrea: During this reporting period, 70,935 cases of AWD (Incidence rate of 858.7 per 100,000 populations) with 163 deaths (CFR of 0.23%) were recorded across South Sudan. Although there was no confirmed cholera and shigellosis outbreak or cases, suspected cholera and dystestary cases were reported from health facilities in the refugee camps (Yida, Jamam, Doro and Patil) and other facilities. None of the stool specimen collected and cultured in AMREF or CDC reference laboratories tested positive for Vibrio Cholera or Shigellosis. As shown in figure 1, the incidence rate of AWD cases per 100,000 popultion reported across the country slightly increased in week 27-39 of 2012 as compared to the same period in 2010 and 2011. The rate of acute watery diarrhoea differs by age group, with the highest rate seen in children less than 5 years of age (58%) as compared to those over 5 years of age (42%). In reference to table 2, WBGS, Upper Nile, Unity and Warrap states recorded the highest AWD incidence, while WES, Unity, Jonglei, Upper Nile and CES states recorded the highest deaths due to AWD. Figure 2 below shows a comparison of AWD incidence rate by Epi-week in 2012. Table 2: Distribution of Acute Watery Diarrhea cases and deaths by state (July State Cases Death IR CFR CES 5534 19 894.0 0.3 EES 4390 3 484.5 0.1 JNG 7941 22 719.6 0.3 LAKES 3720 17 273.8 0.5 NBGZ 2022 0 207.8 0.0 UNITY 10329 26 1484.6 0.3 UNS 14433 21 2002.1 0.1 WBGZ 6935 4 2079.9 0.1 WES 7993 48 828.8 0.6 WRP 7638 3 1303.9 0.0 Total 70935 163 858.7 0.2 In Maban and Yida refugee camps, the trend of acute watery diarrhea slightly decreased this quarter as compared to the previous quarters in 2012, with very few deaths. Heavy rains and floods impacted the sanitation and hygiene practices in the refugee camps but implementing partners made extraordinary efforts to improve the conditions among refugees and host communities so as to reduce the water borne diseases. Despite reported cholera and shigellosis alerts, no confirmed cholera outbreak was reported in the refugee camps. b) Acute Bloody Diarrhea: A total of 23,812 cases of ABD (incidence rate of 288.3 per 100,000 populations) with 65 related deaths (CFR 0.3 %) were reported in the third quarter of 2012. Children below five years of age accounted for 52% of all reported ABD Page 8

cases and 53% of deaths. The overall ABD rate recorded across the country was slightly lower this quarter as compared to the previous two quarters of 2012. Western Equatoria State (WES), Upper Nile, Unity and Western Bahr el Ghazal state (WBGS), states recorded the highest AWD incidence, while WES and Unity states recorded the highest deaths due to ABD. Figure 2 below indicates that the trend of ABD in Maban and Yida remained stable this quarter. There was no confirmed dysentery outbreak in the refugee camps or other counties. Central Equatoria State and Upper Nile states reported the highest incidence of malaria cases, while Lakes, CES, EES, Upper Nile and WBGZ recorded the highest malaria deaths. Since 2010, the number of malaria cases and deaths recorded in health facilities across the country have continued to rise. As of this reporting quarter, data showed the situation to be worse than the previous years. Heavy rains, flooding, food insecurity, limited access to health services, shortage of drugs and increased popultion movements are some contributing factors to the upsurge of malaria cases in this year. c) Malaria: Three hundred and fifty nine thousand, seven hundred and ninty one (359,791) malaria cases (4,355.6 cases per 100,000 popultion) and 360 related deaths (CFR of 0.1%) were reported across South Sudan during this period (July - September 2012). Of these reported cases, 40% were children below 5 years of age and 60% above 5 years of age. Health authorities and cluster partnres reported that more children suffering from malaria were admitted in some main referral hospitals than in the previous years with more deaths. Figure 3 shows that the malaria incidence rate reported during this quarter was slightly higher compared to the previous two quarters in 2012. While the case fatality rate (CFR) was lower this quarter as compared to the previous quarter (0.1% vs 0.2%), and most the deaths occured among children below 5 years of age (72%). The Malaria situation in the country is still considered an emergency and the number of malaria cases and deaths recorded in health facilities across the country have continued to rise. As a result, the demand for more malaria drugs has increased drastically with persistent anti-malaria stockout across the country. WHO is working closely with the Ministry of Health and health cluster partners to reduce the malaria morbidity and mortality among children and women in particular, by responding to the malaria emergencies. WHO and USAID donated additional malaria drugs to the MoH-RSS in order to meet the emergency demand for more drugs. Health cluster partners supported the distribution of the drugs to the state and counties. WHO also supported a number of capacity building trainings for health personal on malaria case management and laboratory diagnosis. The malaria trend in refugee camps in Maban peaked in week 27-31 then slightly declined in the subsequent weeks, while the malaria trend in Yida peaked in week 31 to 39 as compared to the previous weeks. Health facilities serving refugees reported higher malaria cases as compared to those facilities serving host communities in Maban and Pariang. Page 9

UNICEF including effective case management trainings, strengthened surveillance, community awareness campaigns and measles vaccination campaigns. d) Measels: During the quarter, a total of 258 suspected measles cases (incidence rate of 3.12 per 100,000 populations) with two (2) related deaths (CFR 0.8%) were recorded across the country. Of these suspected cases, 61% were in children below five years of age. As shown figure 4, the measles cases reported this quarter were 50% less than cases and deaths recorded in the 2 nd quarter of this year. Measles cases recorded varied from state to state. Western Equatoria, Jonglei and Central Equatoria states recorded the highest number of measles cases, followed by Unity and CES states. Thirty three (33) blood specimens were collected from suspected measles cases and refered to the measles laboratory at Juba Teaching Hospital. Of these specimens, 16 tested positive for measles IgM. Yambio and Nzara counties continue to report increased measles cases, despite the measles vaccination campaigns conducted early this year to respond the outbreak. Following the laboratory confirmation subsequent catch up campaigns have been planned for. South Sudan has experienced increased trends of measles cases since 2010. Health authorities and cluster partners tried to respond to the measles outbreak through vaccination campaigns, but the overall measles coverage is still low. Appropriate public health responses to contain the measles outbreak in different counties were implemented by the health authorities with the support of WHO and e) Meningitis: A total twenty (21) suspected meningitis cases and eight (8) related deaths were reported in this quarter of 2012. All reported cases were sporadic from different counties and none them crossed the alert or epidemic treshhold. There was no confirmed meningitis outbreak during this period, as all CSF specimens tested negative for Neisseria Meningococcal. Fifty seven (57%) percent of the suspected meningitis cases were in children below five years of age. Surveillance was enhanced in all health facilities, especially referral hospitals, while essential supplies were prepositioned in most of the state capitals. f) Cutanoues Anthrax: In this quarter, a total of twenty four (24) clinically confirmed cutanoues anthrax were recorded with no death from Jur River and Wau counties. As seen in figure 5, the trend of the cutanoues anthrax was lower in the 3 rd quarter as compared to the previous two quarters of 2012. Over 75% of all reported cases were in children below 17 years of age. No death related to cutanous anthrax was recorded during this period, and all affected patients responded well to the Ciprofloxacin treatment. The cutaneous Page 10

anthrax outbreak that began in early 2011 has affected people in Jur River and Wau,WBGS and Gogrial West,Warrap state. The cumulative cases recorded as of Septmebr 2012 were 182 cases and 2 deaths. The outbreak is believed to be attributed to the consumption of meat from infected dead animals. Health authorities in WBeG and Warrap in collaboration with WHO conducted intensive health education and community awareness campiagns in the affected communities to discourage people from not eating dead animals. KEMRi/CDC reference laboratory in nairobi for further analysis. Of these specimens, 27 tested positive for Heptitis E virus. All positive patients for HEV were from the refugee camps in Maban, as a results, the Ministry of Health together with UNHCR and WHO declared hepatitis E virus outbreak in MabanThe weekly new cases recorded in the major camps remainded high as of the end of the quarter (september 2012). Table 3 details the recorded numbers of AJS in the camps with Jamam camp recording over 50% of the new cases, followed by Yusuf Batil and Gendrassa. g) Acute Jaudice Syndrome: A total of 894 of suspected Acute Jaundice Syndrome (AJS) cases and 27 related deaths were reported from all the states this quarter (refer to figure 6).. Over 90% of them were recorded in Maban refugee camps, Upper Nile State (refer to table 6 for geographical distribution of cases and deaths). The majority of the suspected cases were adults. Other states that recorded AJS include CES, EES and WBGZ. Sixty five (65) blood specimens were collected from suspected AJS cases and refered to h) Avian Influenza: A total of twenty five (25) suspected cases of influenza like illnesses with no death were reported from Upper Nile and EES in particular. No laboratory specimens were collected with the majority of the cases being children. 2.2.3 Challenges 1. Heavy rains and flooding hampered access to health facilities and vulnerable groups in high risk states. 2. Additional returnees and refugees arrived in South Sudan during this period, while more people were displaced due to flooding and tribal clashes. These increased population movements hence negatively impacting on the availability and accessibility of social services including health, education and water and sanitation. 3. Unpaid or prolonged delay of monthly salary among health workers has negatively impacted the continuity of health services Page 11

and surveillance activities due to economic austerity imposed by the government. 4. Many health facilities received late regular drug supplies, while other facilities may not have received the regular drug supplies at all. This was mainly seen in health facilities in Upper Nile state and parts of Unity state. 5. The severe shortage of anti-malaria drugs across the country, despite the distribution of regular drugs supplies and extra antimalaria drugs across the country remained a challenge. 6. More health facilities were found not to be operational due to unpaid staff salary or lack of regular drugs. 7. Severe shortage of fuel in the peripheral states and counties reduced the movement of health authorities and cluster partners to respond to the outbreaks or emergencies. 2.2.4 Recommendations 1. Need for the procurement and distribution of more anti-malaria drugs to health facilities across the country, referral hospitals in particular. 2. Regular payment of monthly salary among health workers in order to maintain health services and keep health facilities operational. 3. Increase timeliness and completeness of reporting from health facilities, county and states in collaboration with state and county health authorities and partners. 4. Continue to enhance the early warning surveillance in the refugee camps and preposition adequate emergency supplies in high risk states 2.3 Polio Eradication Initiative (PEI) The Polio Eradication Programme (PEI) continued its activities to ensure a polio free South Sudan. This report outlines activities implemented for the third quarter (July to September 2012). In this quarter the PEI continued with its fight to obtain polio free certification status by instituting a number of activities in collaboration with its partners as well as sustain gains made in the previous quarters. Acute Flaccid Paralysis (AFP) surveillance was intensified with all surveillance indicators at optimal level yet no case of wild polio virus was detected for the past 39 continuous months. Updated Polio free certification report was submitted to the regional certification committee for consideration. South Sudan PEI was fully represented in the Horn of Africa Technical advisory group (HoA/TAG) meeting held in Nairobi with other countries to review progress of the implementation of polio eradication activities in the country. So far the HoA/TAG was impressed with the progress made. WHO EPI/PEI support to the routine immunization program was strengthened in the quarter by providing funds for eight states to carry out routine vaccination outreach activities. Technical support for training, monitoring and supervision was also conducted WHO staff. In addition, the organization supported South Sudan s new vaccine application process by hiring services of a consultant to cost the comprehensive multiyear plan, a prerequisite for the new vaccine application process so far made by South Sudan. With this achievement, South Sudan was able complete and submit the new vaccine application document to GAVI for consideration. In order to ensure that no virus is imported into South Sudan, three important cross border meetings were held this quarter with its neighboring countries to plan for cross border surveillance and Supplementary Immunization Activities (SIA) to ensure that the borders are strengthened. In spite of the above progress, Page 12

the PEI program faced numerous challenges in reaching its desired objectives and goals. Key among them was; restricted movement as a result of insecurity and floods resulting in low and minimal supervision; the fragile security situation in blue Nile state that precipitated huge influx of refugees into South Sudan with its accompanying health problems and shortage of fuel resulting from the shat down of oil production in the country resulting in high fuel prices and other commodities. This poses a severe constraint on the budgets of most activities. As a way forward the WHO PEI program will intensify AFP surveillance activities in all and bomas to ensure early detection of circulation of wild polio virus for onward investigation as this is the only way to ensure and sustain the gains made so far. Above all continue to support the Ministry of Health in building the capacity of its workforce and quality implementation of SIAs. The chart below shows classification of cases The table below shows the virological classification of the 236 AFP cases detected in 2012 reporting period. These included 199 Non-Polio AFP cases, 7 pending for ERC plus 29 pending for laboratory results. One case was confirmed as Vaccine Derived Polio Virus (VDPV) case. 2.3.0 Surveillance 1. Acute Flaccid Paralysis (AFP) Surveillance During this reporting quarter, AFP surveillance was enhanced to high level sensitivity. This was done by mainly focusing on active case search, investigation and collection of samples from all suspected AFP cases and their contact and collection of samples from healthy children in silent counties. 2. AFP Surveillance indicators In this reporting period, all major AFP surveillance indicators met the international standard. Non-Polio AFP rate stands at 3.86, Stool Adequacy 96%, NPEV 17.4%, whereas sabin like rate recorded 2.9%. Chart #2: Non-Polio AFP Rate and Percent AFP Cases with Adequate Specimens by Year / 2004-2012 These yielded to the desired results, as a total of 236 AFP cases were detected investigated and samples collected for analysis as of week 39 of 2012 alongside with 639 contact samples were collected. Out of the 236 cases, 77 cases were detected in the period under review (July September, 2012). Page 13

All states have reported Non Polio AFP rate (NAFP rate) above 2 per 100,000. However, at the second administrative level, 74.7% of the counties reached NPAP of 2 per 100,000 populations, 19 percent are in the region of 0.01 and 1.99 per 100, 000 population whereas the rest 6% were silent (have not reported any case of AFP for a period of 6months) for 2012 However, at the second administrative level, 74.7% of the counties reached NPAP of 2 per 100,000 populations, 19 percent are in the region of 0.01 and 1.99 whereas the rest 6% were silent (have not reported any case of AFP for a period of 6months) for 2012. 2.3.1 Routine Expanded Programme for Immunization (EPI) 1. Financial and Technical support for routine vaccination In the quarter under review, WHO boosted technical support to the State Ministries and counties of health by releasing funds to support routine vaccination and outreach activities in eight states. The funds were used to carry out outreach activities in counties and payams. In addition, all WHO personnel at the state and county levels provided technical support to the ministries of health in monitoring and supervision of routine vaccination activities. 3. Measles Surveillance Measles case based surveillance continued expanding this quarter with 74 cases detected. The chart below shows the classification of the cases. 2 Costing for Comprehensive Multi year plan(cmyp) In this quarter, WHO provided technical assistance to the Ministry of Health RSS through - the services of a costing expect who cost the comprehensive multi year plan for 2012 2016. The document was finalized and presented to the Interagency Coordination Committee (ICC) for approval. This document forms a major component of the new vaccine application process that was submitted by South Sudan to GAVI for consideration. Page 14

3. Funding for Routine EPI Outreach activities The WHO EPI/PEI support to the routine immunization program was strengthened in this quarter. This was done by providing funds to eight states to carry out routine vaccination outreach activities. 4. Maternal and Neonatal Tetanus Elimination Campaign In collaboration with UNICEF, the programme provided technical support to the central Ministry of health to plan a phased Maternal Neonatal Tetanus Elimination (MNTE) campaign. The campaign will be carried out in three phases and is aimed at eliminating maternal and Neonatal tetanus from South Sudan. All the preparatory work for the campaign was completed. This campaign licks off in the fourth quarter starting with 3 states. 2.3.2 Coordination 1. The ICC Meeting WHO fully participated in the Inter-Agency Coordination Committee for Immunization services meeting for the quarter under review. Valuable contributions for the adoption of the Comprehensive Multiyear Plan (cmyp) and new vaccines application documents were made. 2. Meeting with Health Forum In the quarter under review, WHO participated in the health forum group meeting to solicit their involvement in the routine vaccination program and the SIAs. 2.1 Cross-border activities The EPI/PEI program held two important cross border meetings this quarter with neighboring countries of Ethiopia and Uganda in Gambella and Kajo Keji respectively. The meetings were aimed at drafting a common plan of activities for surveillance and routine EPI to prevent importation of the polio virus. 2.3.3 Challenges 1. Restricted movement resulting in low and minimal supervision caused by insecurity in some areas 2. Influxes of refugees due to conflicts in South Kordofan and Blue Nile States (in the Republic of Sudan) 3. The rapid turnover of health staff poses a challenge to the PEI programme. 4. The very poor infrastructure and very hard terrine as well as the poor transportation system immensely deprive many parts of South Sudan of PEI programme services. 5. The escalating living costs lately posed a huge burden on the program due to the sky rocketing costs of fuel and transportation. 6. Lastly the persistent lack of both accountability and ownership of the program from the health officials at different levels especially at the state and county levels which is usually the major make or break factor hinders the success of the program. 2.3.4 Way forward Intensification of AFP surveillance activities in all Payams and bomas to ensure early detection and circulation of wild polio virus for onward investigation as Page 15

this is the only way to ensure and sustain the gains made so far. Support supervision on the implementation of Reaching Every County (REC) approaches (Routine EPI) WHO will be further work with MOH/ RSS to implement polio eradication activities to maintain South Sudan s polio free status by conducting supplementary immunization activities, routine immunization, strengthening AFP and other Vaccine preventable diseases (VPDs) surveillance. WHO EPI/PEI program will support the MOH in the upcoming National Immunization Days in November and December as well as the phased Maternal and Neonatal Tetanus Elimination (MNTE) Campaign. 2.4 Guinea Worm Eradication Program There is noticeable positive progress in South Sudan following a 50% reduction of guinea worm cases in 2012. The program is currently in the peak guinea worm transmission season, as such WHO, The Carter Center and UNICEF are working extremely hard to break the transmission, strengthen surveillance and improve the supply of safe drinking water. During the last three month of July, August and September 2012, a total of 111 new dracunculiasis cases were reported compared to 186 cases over the same period (July-Sept) in 2011. The total numbers of cases reported in South Sudan between January to September 2012 were 502 compared to 980 cases over the same period in 2011. Globally, a total of 521 cases have been reported this year as seen in the table below. The global eradication of guinea worm largely depends on the efforts carried out by the Ministry of health Republic South Sudan and its key partners, namely WHO, The Carter Center and UNICEF. 2.4.0 Guinea worm outbreak in kapoeta East County: It s important to note that 81% of all cases reported between January and September were from kapoeta East county, Eastern Equatoria state (EES)of South Sudan, the remaining cases were reported from: Kapoeta South, Kapoeta North also in EES, Lakes and Warrap states while one case from Western Bhar El Ghazal state. Between July and September 2012, a total of 231 guinea worm rumors were registered, 203 of them were investigated and three were confirmed as guinea worm cases. The three cases were detected in Gogrial East County, Warrap state. Two other specimens were sent to CDC collaborative center for confirmation (one from Gogrial East and the other one from Nyiror County, Jonglei state. 2.4.1 Health workers training During this quarter, WHO supported the training of health workers trainings in: Mundri East, Mvolo county and Jur River county. A total of 84 health workers were trained on dracunculiasis disease surveillance, importance of documentation, guinea worm Page 16

specimen collection, preservation and transportation. 2.4.2 Community based surveillance In this reporting period, the programme supported training of 192 community based surveillance volunteers from the counties of: Jur River County, Gogrial East and Gogrial West in Warrap state, Mvolo and Mundri East in Western equatoira state and Jur River County in Western Bahr el Ghazal. Due to the few numbers of health facilities and health workers, the trained community based volunteers played a vital role of an extended arm of the IDSR and strengthening of surveillance between health facilities and the community. Guinea worm disease active case search in Warrap state 2.4.4 Increasing awareness on dracunculiasis disease The World Health Organization supported an advocacy and awareness campaigns in Juba County and among Military personnel s in Unity state. During this time a total of 78 community leaders in Juba and 102 senior SPLA officers were sensitized on Guinea worm disease. This campaign among the military personnel was conducted to ensure that soldiers are well educated on guinea worm disease. Those sensitized included personnel from endemic areas so as to ensure that they do not become agents of transmission. More than 240 guinea worm posters were also distributed in the community. 2.4.5 Strengthening guinea worm crossborder collaboration WHO supported three participants to participate in the guinea worm/polio crossborder meeting conducted in Gambella region of Ethiopia. During this period, the team marked key crossing points, dynamics of population movement across the South Sudan and Ethiopia border and devised ways of improving joint surveillance along the border for the guinea worm and polio disease. 2.4.3 Strengthening supervision In this quarter, WHO dispatched the monthly supervision allowances and fuel costs for 80 county surveillance Officers and state surveillance officers. The funds dispatched in July are meant to support supervision work for a period of six month. Payment is given only to surveillance officers conducting field supervision visits and those who submit monthly reports. This has increased the number of surveillance officers reporting from less than 50% to >85% in September 2012. Discussion between South Sudan and Ethiopian polio/guinea worm teams during the cross-border meeting in Gambella Ethiopia Page 17

2.4.6 Challenges 1. The current outbreak of guinea worm cases in Kapoeta East county Eastern Equatorial state and the upsurge of cases in Gogrial east county Warrap state pose a challenge on the program. 2. The dynamic population movement especially among the Toposa nomadic community where most cases have been reported this year. 3. The countrywide continued low supply of safe drinking water especially in guinea worm endemic areas (< 25%) 4. Low motivation among some health workers and surveillance officers as a result of lack of salaries from the MOH especially in Lakes state. 5. Reduced access to Northern Jonglei state due to flooding and poor road access. 6. Insecurity in Pibor County due to ethnic fighting that led to cancellation of some activities (training and supervision). 2.4.7 Plans for the coming quarter 1. Continue to support the MOH at the state and national level to improve and strengthen guinea worm disease surveillance at all levels. 2. Conduct a communication workshop in Juba and develop a countrywide communication strategy for guinea worm disease that could be adopted by other programs. 3. Conduct guinea worm assessments in the four counties of Gogrial east, Jur River county Nyiror and Cueibet County. 4. Conduct regional and National Program review in the states and Juba. 5. Write the 2013 plan of action and proposed budget for the South Sudan guinea worm program 6. Participate in the upcoming regional guinea worm cross-border meeting between Kenya. Uganda, Ethiopia, Sudan, South Sudan and Congo in Entebbe Uganda 7. Continue to support the South Sudan GWEP Task Force meetings 2.5 Tuberculosis During the third quarter, WHO South Sudan continued providing support to CUAMM (DOCTORS WITH AFRICA) to deliver TB services in Greater Mundri County, Western Equatoria State. To support the health education and promotion of the TB section, WHO distributed various TB IEC (information, education and communication) materials to two TB units in Central Equatoria State. WHO continued providing support to the MOH for the revision of Transitional Funding Mechanism (TFM) for TB program. WHO further supported the MOH with the development of Patient-Centered Treatment (PCT) guidelines. The biggest challenge facing TB control program in South Sudan is the high default rate. Therefore, in order to improve access to treatment for patients, the National TB/Leprosy/Buruli Control Program (NTLBP) of the South Sudan Ministry of Health developed the PCT guidelines. 2.6 Health Systems Strengthening The health systems development programme implements activities that contribute to the attainment of WHO strategic objectives 10 and 11. This report outlines major activities carried out between July and September 2012. Page 18

2.6.0 Leadership and Governance During the third quarter, WHO continued to participate in and conduct activities that contributed to the strengthening of leadership and governance in the health sector of South Sudan. 2.6.1 Donor Coordination and collaboration WHO consolidated the functioning of the H4+ (UNICEF, UNAIDS, UNFPA, WHO,) coordination mechanism for Maternal, Child and Newborn Health (MCHN) actions among the UN agencies. Besides convening, chairing and providing secretarial support for this forum, WHO lead the development of the H4+ position paper on Maternity Waiting Homes (MWH) which will be piloted in Bor Hospital, Jonglei State. Other technical areas deliberated upon during H4+ technical and coordination meetings during this period include: feasibility of introducing marginal budgeting of bottlenecks (MBB) in South Sudan; H4+ terms of reference; H4+ advisory role to the Ministry of Health senior management; options for strengthening coordination within the health sector; H4+ position paper on Community health workers/community midwifes; concept note on H4+ joint programming. WHO also participated in the monthly United Nations Program Management Team (PMT) meetings. WHO led a sub working group commissioned by the PMT in the process of reviewing and revising the health indicators of the monitoring and evaluation framework of the United Nations Development Assistance Framework (UNDAF). Other issues discussed during the PMT meetings during this period include: the Peace Building Support Plan, South Sudan Development Initiative and the New Deal all of which are expected to impact on the way UN agencies support South Sudan. To foster information sharing and transparency of UN programs, the PMT endorsed the establishment of a web based 4Ws matrix (who is doing what where and when), in which all agencies are expected to input their data. Furthermore, WHO lead the process of consolidating inputs and writing the health section of outcome three of UNDAF midterm review report. WHO participated in the Health Development Partners monthly meetings convened by the Joint Donor Team. In addition to the anticipated drug shortages, the team also discussed issues on: the feasibility of introducing Community Based Disease Surveillance and linking it with broader early warning systems; feasibility of introducing performance based financing in South Sudan and the options for strengthening South Sudan AIDS Commission s coordination role and linkages with Ministry of Health. DFID and USAID have secured additional funding for drugs and are in dialogue with MOH on the possible mechanisms of expediting availability of these drugs. The central MOH, directorate of planning and donor coordination convenes a monthly Health Sector Working Group (HSWG). During this quarter a similar meeting was convened for which WHO participated.. In this meetings, the HSWG dialogued on options for improving mechanisms for tax exemption of health commodities imported by health development partners; the current health commodities pipeline and contingency measures that will be used to respond to anticipated shortage of health commodities by early next year; finalization of the operational plan of the Health Sector Development Plan (HSDP) and the operationalization of the Local Services Support AID Instrument (LSSAI) within the health sector. Finally, the organization participated in the UN Gender Technical Working Group (GTWG) meetings. The meetings explore how UN Page 19

agencies should mainstream gender in all programs. Terms of reference (TOR) and work plan for the GTWG was also developed and brain storming on implementation modalities discussed. 2.6.2 Development of Policies, Strategies and reports In collaboration with the Ministry of Health and other development partners, WHO participated in the development of the Health Sector Service Delivery Framework (SDF). The development process is being led by the Ministry of Finance and Economic Planning (MOFEP). As a follow up, WHO held dialogue with a team from MOFEP to explore linkages and synergies between SDF and the operational plan of the HSDP as well as the Basic Package of Health Services at primary and secondary care level. The agency also participated in the development of the strategic document on Core Functions under Austerity, during which it provided inputs for the health aspects. This development process was led by the UNDP in collaboration with the Ministry of Health. During the quarter, the Regional Coordinator s (RC) requested the WHO country office (WCO) to develop a paper on Health Systems Strengthening (HSS) baseline and priorities for South Sudan. In response, the WCO adapted strategy options from the RC position paper ensuring their relevance and suitability in addressing the HSS challenges and priorities in South Sudan and set these priorities in the national Health Sector Development Plan. Dialogue between the WCO and EMRO identified the areas in which the later would support WCO and MOH to operationalize, namely: health coordination, HIS strengthening and Health commodities security. 2.6.3 Strategic Information WHO, participated in the monthly Monitoring and Evaluation (M&E) Technical Working Group meeting that was convened by the central MOH department of M&E. The main issue discussed was the first ever annual Health Management Information Systems report for South Sudan; challenges of production and distribution of HMIS tools and completeness and timeliness of reporting. WHO is in the processing of securing a team from the EMRO regional office and a consultant who will support the MOH, department of monitoring and evaluation to develop a health information system strengthening strategy based on the health metrics network framework. 2.6.4 Maternal Child Neonatal Health WHO convened and held the project steering committee meeting of the CIDA funded strengthening emergency obstetrics care in hospitals in South Sudan project. During this meeting the selection of the hospitals for the second phase of the project was finalized. In collaboration with the Ministry of Health- Reproductive health directorate, WHO conducted assessments in Wau and Malakal hospitals as part of the process of determining hospitals in which the CIDA funded project will be implemented in 2012-2013. The organization continued to proactively participate in the technical and planning meetings for the upcoming maternal mortality survey and emergency obstetrics care assessment for South Sudan. This meeting involved participants from UNICEF, UNFPA, MOH and SSBS. In addition, WHO participated in the Post Partum Hemorrhage (PPH) technical working group meeting that discussed the strategies for Page 20

piloting the use of Misoprostol for prevention and management of PPH in Eastern Equatoria State. And finally, WHO hosted a team from UNFPA HQ and regional office for Africa, who were on a visit to explore how WHO and UNFPA can collaborate in Adolescent and Youth Friendly health services programming. 2.7 The African Programme for Onchocerciasis Control (APOC) The African Programme for Onchocerciasis Control (APOC) continued to support the South Sudan Onchocerciasis Taskforce (SSOTF) in a bid to establish effective and self-sustainable community-directed ivermectin treatment (CDTI) throughout the onchocerciasis endemic areas. Onchocerciasis is endemic in 9 out of 10 states in South Sudan. The CDTI strategy relies on community participation for the distribution of ivermectin to the targeted population. Project Coordinating Officers, County OV Supervisors, Staffs from Front Line Health Facilities (FLHF) facilitate the CDTI process by organizing communities to participate in CDTI activities. Community selected Community Drug Distributors (CDDs) who were trained conduct community censuses, provided treatment with ivermectin and keep records of the households treated. 2.7.0 Mass drug administration exercise At project level, the main activities carried out include: completion of the training for both new and old CDDs and commencement of the distribution of mectizan to the communities in the payams and bomas in all the endemic 9 states. All the states and counties covered by the 5 CDTI projects also had their 2012 supplies delivered at their respective state ministries of heath and county health departments. The task to treat over 6 million people across the country with mectizan this year commenced during this quarter. 2.7.1 Field visits for technical support to the CDTI project staff WHO conducted field visits to three project areas of North Bahr el Ghazal, East Equatoria and Warrap states. The visits to the CDTI projects were to monitor the progress of implementation of CDTI project activities; provide support supervision to the project and frontline health facility staff; hold meetings with State and County Health authorities; and conduct community visits to community members and leaders. Meetings to continuously advocate for support and involvement in CDTI work were also held with the Director General for Health, the Director for preventive and community health and some of County Health Officers. Communities were also visited for verification of CDTI data received and for interaction with communities to find out how they are involved in CDTI work. 2.7.2 State level planning meeting for relaunch of onchocerciasis control activities During the 3 rd quarter, a field visit was conducted to East Equatoria CDTI project to carry out a detailed planning session with the state health authorities, that included the Minister of Health, the Director General of Health Services, the State Planning Officer, the Project Coordinating Officer, and the Torit County OV Supervisor. A detailed plan and budget for re-launching of the CDTI program in the state was prepared and submitted to APOC management. Once approved, the format used in this proposed plan and budget will be used as the base for preparation of similar budgets and plans for other states after taking into consideration peculiarities in individual states. Page 21

2.7.3 Compilation and submission of annual technical reports to APOC Management The Annual technical reports for the 2011 activities were compiled and submitted to APOC HQ at the beginning of this reporting period. The submission was done on schedule as required at the end of July 2012. These reports provide detailed information on the performance of the CDTI projects, challenges faced, and different funding sources among other aspects of CDTI project implementation activities in the reporting year. 2.7.4 Attendance of the annual meeting for NOTFs in Ouagadougou, Burkina Faso APOC Technical Advisor attended a one week meeting for the National Onchocerciasis Task Forces (NOTF) held in Ouagadougou, Burkina Faso in September 2012. This annual meeting brings NOTFs from 20 countries. During the meeting the NOTFs present data on activities implemented during the previous year, have it peer critiqued, discuss challenges faced and suggest solutions to address challenges. It also provides a forum for National Onchocerciasis program staff to interface with APOC Management staff so as to address any pending project related issues. 2.7.5 Achievements 1. Monitoring and supervision of mass treatment with mectizan and data collection process across the country in collaboration of SSOTF. 2. Surveillance and monitoring of adverse reactions to mectizan treatment across the country; with special attention to Western Equatoria CDTI project due to loa loa coendemicity. 3. Preparation of 2013 Mectizan application for submission to MERCK and. 4. Continued Technical support to the SSOTF and the CDTI project staff. 2.8 Health promotion and prevention and, advocacy and communication The organization continued supporting the MoH with health education and promotion (HEP) message validation and supported the ministry of health in coordinating health partners working in the area of HEP. Two meetings were held this quarter and Terms of Reference for the Communication Technical Group, an advisory group to the MoH on Behavior Change Communication submitted to the Director General for Public and Community Health for validation was validated during this quarter. Support was also provided to the ministry of health by supporting the review of Knowledge, attitude and practices tools to be used for an upcoming KAP survey in the country. Other activities supported were; the provision of IEC materials for World Rabies Day and World Heart Day. 3.0 Conclusion In the coming quarter, WHO will continue to support the MoH by strengthening the governmental health systems in South Sudan through the provision of technical support to the states and counties to implement life saving health interventions, improve the accessibility and utilization of services while continuing to offer technical support to the state health teams in emergency health planning, response, monitoring, supervision and coordination and, advocating for more support and attention to the states. Page 22