southern sudan health system assessment - Health Systems 20/20

State level
As described in the National Health Policy, the state level is responsible for the overall management of
county health services. Specifically, this task includes monitoring, evaluating, and auditing contracts with
NGO health providers; managing public providers; allocating resources; doing strategic planning; and
coordinating the different actors within the health system.
Interviews with state-level officials reveal that there is considerable confusion as to the degree of
authority the state level has vis-à-vis the central level. All states interviewed were familiar with the roles
and responsibilities set out in Box 5; however, they also commented that they were unclear on how to
operationalize those roles, and that there was significant overlap between certain state-, county-, and
central-level duties. States also commented that they lack the critical resources needed to accomplish
their roles, including basic skills in financial management and bookkeeping, auditing and accounting, and
planning and administration. According to our interviews, the dearth of skilled staff was due to limited
and irregular finances flowing from the central level for salary support. Thus, all but one state (Central
Equatoria) has a functional director of planning. State health management committees are intended to
form the backbone of planning, monitoring, and evaluation of state health activities; however, most
states do not have functional committees that meet on a regular basis. In those states where
committees do exist, the committee members are unclear of their roles, responsibilities, and mandate,
and lack the critical management tools such as supervisory checklists to carry out their functions.
During the war and its immediate aftermath, the weak capacity at the state level was mitigated by the
fact that most health care was financed, managed, and delivered by independent NGOs. However,
Southern Sudan is now in the process of transition, and development of the state-level management
function is critical. The process of implementing the MDTF Umbrella Program for Health has recently
begun to move rapidly, and a key part of the program involves contracting with NGOs and faith-based
organizations (FBOs) to provide services. States will be responsible for managing these contracts to
ensure appropriate delivery of PHC, including immunization; therefore, the development of management
capacity is essential.
County level
One of the conclusions that emerged from Sudan’s first National Health Assembly was the critical role
of the counties in implementing the BPHS strategy. Counties, being the closest unit to the health
facilities and to the communities, are responsible for supervising, monitoring, and guiding health service
delivery. They also serve as the main vehicle to identify local needs, both at the facility and community
level, to feed into the strategic planning process at the state level. Counties are to serve as the main
implementing arm of the states, and will be critical in the day-to-day management of service delivery
contracts with NGOs, FBOs, or other organizations at the facility level.
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