The World Bank has responded to a report published by Radio Tamazuj on Monday as part of its series 'Healthcare in crisis: Understanding South Sudan's collapsing health system.”

“In Name Only: The World Bank at the centre of a Humanitarian Crisis,” describes the three-way partnership of the World Bank, South Sudan's Ministry of Health and aid group IMA World Health in delivering healthcare services in two states of South Sudan, Jonglei and Upper Nile, the majority of which are controlled by South Sudanese opposition groups.

Although the World Bank prepared answers to questions from Radio Tamazuj last month, which were quoted extensively in the original report published by Radio Tamazuj, the bank has also prepared a follow-up statement to respond to the report, which are published here in full. The statement will also be cited in the comments section of the reporting series.

This eight-point statement was shared with Radio Tamazuj today by Gelila Woodeneh, a communications officer for the World Bank in Ethiopia, referring to eight areas in which the Bank considers there to have been misleading statements or “factual discrepancies” in the reporting.

1. Humanitarian support versus support for emergency service delivery:  World Bank financed HRRP is not a humanitarian project but rather an emergency operational funding mechanism to support health service delivery for primary health care services in the states of Jonglei and Upper Nile. There is a distinct humanitarian support action which is spear-headed by other partners whose function is to provide for the humanitarian needs of the affected communities across the country. These two approaches should not be confused.

2. Your report states that “the Rapid Results Health Project was designed in 2012 - a time of peace - with the assumption that the government in Juba would be a partner throughout. Yet four years on, with Upper Nile and Jonglei devastated by conflict and rebel groups controlling large swaths of territory, the design of RRHP remains largely unchanged. The result is the hugely challenging task of achieving a World Bank program designed in peace but implemented in war.”

This statement is not accurate. While the HRRP was designed during times of relative peace, it must be recalled that Jonglei and Upper Nile were regions frequently affected by conflict long before 2013. Tensions with Sudan, ethnic violence, cattle raiding etc. were a constant feature of these two states for decades. Therefore, HRRP was designed within the context of fragility, conflict and violence. In fact the decision to provide direct support to CHDs was done in consideration of the local context.

The HRRP offers great flexibility, allowing both the Government and the CSDO to adjust operations (within agreed upon parameters). It has also been highly adaptable since 2013. In the face of war the model served as a bridging gap for service delivery. The humanitarian component in these two states were and continue to be handled through a defined humanitarian response mechanism. Your article does not note nor appreciate the dual system of delivery of service/ humanitarian care but simply lumps them together as a failure to respond to crisis. This duality, the complex context and long history of underinvestment in the sector, need to be reflected more accurately in your report.

3. The Ministry of Health is a custodian of health and interlocutor for implementation of health for all people of south Sudan. Although funds are provided to the government, due to capacity limitations at both central and county level, a third party firm was contracted to support implementation in the two states. So the MoH is not a middleman in implementation as it is actively supervising the IMA in its activities.

Contracts signed between MoH and IMA undergo a comprehensive drafting by MoH, and is reviewed by State MoHs before being finalized. The MoH, State MoHs, CHDs and village committees are responsible for reviewing results before IMA can receive its payment. Any adjustment to terms of the contracts has to be carefully reviewed by MoH.

The role of IMA is much broader than that of a fund manager. In addition to playing a coordinating role in the states they support, as you have rightly mentioned IMA also delivers care services using their vast global experience in operating in conflict affected areas.

The whole issue of third party direct financing was to supplement the capacity of the government and make sure that services get delivered while also focusing on capacity building over the medium to long term; it was also necessary to ensure funds are used for the intended purposes, and guarantee equity and transparency in service delivery regardless of who was in control in the two states. Your report does not highlight the role of the project in mitigating these impacts although we provided the information to you.

4. Your report also states that “While many aid donors shifted their funding from development partners to emergency NGOs, the World Bank stayed the course, continuing to fund the RRHP through the national government, though that same government was accused of actively undermining the health services in opposition areas of Upper Nile and Jonglei.” 

This statement does not even take into account the statements we provided to you on this matter. Once again, IMA is coordinating and implementing on behalf of the Government in the states of Upper Nile and Jonglei. The arrangements are governed by a contract that ensures services are delivered in both states as per agreement.

The government cannot change the terms of the contract (and IMA cannot agree to it as this would affect their performance and payment) without consulting the CHDs and NGOs that provide services. If there are challenges that result due to conflict and war, IMA works through CHD or NGOs which are servicing these areas. Your report fails to mention how the use of a third party contracting has actually helped to improve service delivery, and what would have happened in their absence.

5. The assertion that the model being used is outdated is as erroneous as it is misleading. Your report wants to actively compare the model the World Bank is using to that commonly used in a humanitarian situation, which the HRRP is not. Regardless of the situation an element of systems support needs to be present to ensure that when peace returns, there is a baseline to build from and you cannot ignore the facts and assume systems are not relevant in the context of South Sudan.

6. You noted that: “Akobo County Hospital in South Sudan’s Jonglei state is running out of medicine. “We haven’t received any drugs since last year,” one health worker wrote Radio Tamazuj in a recent email. “When patients come to hospital, we have nothing to offer them... You cannot even find injection needle in Akobo hospital.” The dire situation is despite the fact that Akobo County Hospital is part of a 63 million dollar World Bank-funded initiative called the Rapid Results Health Project.” This is misleading. As mentioned in our previous responses to you, HRRP is intended to supplement government resources, and not cover the costs of running the whole health system in the two states. The World Bank is not in a positon to provide such level of support. In fact, the HRRP was designed to mostly support delivery of 5 specific interventions. Since the costs of running hospitals are expected to be covered by the Government, HRRP support to county hospitals is minimal. While the World Bank acknowledges the great challenge that lack of pharmaceuticals presents to service delivery, it must be noted that the HRRP was not expected to cover these costs.

7. You note that “the World Bank has allocated more than $8 million in recent years to strengthen the health ministry’s Directorate of Planning and Coordination to “plan, manage and monitor grants and contracts” with NGOs and other service providers, according to World Bank documents” and the following: “The Bank initially allocated $5 million for building the capacity of this management unit (later increased to nearly $9 million) while giving another $23 million (later increased to $54 million) for actual service delivery functions.”

It is important that the article reports accurately on what the project actually supports, the website we shared provides all this information. The objective of the Bank supported Health Rapid Results Project is to (i) to improve the delivery of high impact primary health care services in Recipient‘s states of Jonglei and Upper Nile; and (ii) to strengthen coordination and monitoring and evaluation capacities of the Ministry of Health. The report is probably referring to Component 2 of the project which aims to 1. Strengthening Grant and Contract Management and 2 Bolstering the Monitoring and Evaluation Function of the MOH. A significant proportion of the $8.8m allocated for component 2 (after AF1) goes into ensuring that there is a steady stream of independent and credible data on health sector performance, not only from the project supported states but from the whole country.

The World Bank has therefore supported the following nationwide surveys: Health facility surveys (HFS) and household surveys using LQAS. The resources have also supported the strengthening the HMIS which is the backbone of periodic data on health from the sector. The component has also supported the overall management of the project from the Government side, including resources for procurement, financial management and operational costs.

8. Given the war, destruction, and looting and population displacement, fact that the project has up to 71% of health facilities functioning and providing services is a great success story in and of itself. The challenges in logistics and availability of funding have made the whole issue of pharmaceutical financing very complicated. If in normal countries stock-outs are common, what about in a conflict and fragile country?

The current data shows that SS given the concerted donor effort in terms of pharmaceuticals has been able to provide more pharmaceuticals support than has been the case in other countries. Your report should also accurately reflect these positive achievements that are a reflection of continued donor commitment during highly turbulent times for the country.