National Systems Mapping Main Findings 1 st December

National Systems Mapping: Main Findings 1 st December 2016, with selected draft updates December 2018 Updated December 2018

Executive Summary of systems mapping updated to Dec 2018 – 1 – overall observations • This mapping of Management Information Systems was originally undertaken in 2016; it was updated in Autumn 2018 for the latest position • A number of significant national information systems relevant to the health sector have been established from 2005 onwards, including Pharmaceutical Management Information Systems (PMIS), Human Resource Information Systems (HRIS) of MOH and MOLPS, South Sudan Electronic Payroll System (SSEPS/SSEPS II), Integrated Financial Management Information System (IFMIS), and District Health Information System/Health Management Information System (DHIS/HMIS). • But while most of these systems remain functional in principle, the data in them has been updated progressively less regularly, or not at all, and there has been limited follow up on submissions of reports. This pattern, which had been identified in 2016, has become more pronounced in 2018. The Aid Information Management System (AIMS) at the MOFEP (Aid Coordination office) has fallen completely into desuetude. • Alone of these systems, the Nutrition Information System was found still based outside GRSS, with the (UN) Cluster, however it reported to have reports being submitted by 40 partners on a monthly basis. It does not link in to national systems but serves the sector and has prospects for linkage. After much consultation Cluster shared information in Autumn 2018, and Mo. H has been discussing level of presentation on SSHI • A key challenge for all systems is to have regular reporting from all intended units; this challenge has been exacerbated by: • • • new administrative structures under the post-2015 redivision of the subnational administrative boundaries resulting in newly appointed staff who are unfamiliar with the systems and/or their responsibilities (IFMIS, especially, all, more generally) donor support ceasing, in some cases abruptly (SSEPS, HRIS) lack of continued follow up to ensure data received (HRIS) The new administration system still under-capacitated, and those originally trained on systems having been transferred to other duties (though, in most cases, still working within the Public Service) More areas being affected by conflict than in 2016, resulting in reduced support to systems in those areas, and reduced compliance • The cessation or abeyance of various projects supporting systems in different sectors (HSS/HPF 2), coupled with the effects of conflict, fiscal crisis and administrative changes have led to partially divergent geographical coverage for key systems • Mapping these systems, their purpose, coverage, and management, and providing recommendations for rationalising these can save costs whilst improving efficacy, accountability and strengthening the health sector. A clear understanding of the systems’ functions, status and requirements to reach full operating functionality can help partners 2 Updated December 2018 prioritise assistance accordingly

Executive Summary of systems mapping updated to Dec 2018 – 2 – system-by-system System Latest update – use Skilled staff Consultant recommendations PMIS (Pharma) Not up to date Still in Directorate of pharmaceuticals HPF to prioritise supporting its operation, as part of its work on Pharmaceutical Supply HRIS (Human Resources) Not up to date in health, but did in 2015 have extensive data holdings for six States; extensively used in education to support incentive payments to 30, 000 + teachers Still in SMo. Hs, Mo. H Directorate of Finance, Mo. LPS Mo. H to work with HPF and its implementing partners, in the context of implementation of the new Harmonised Health Worker Incentives Scale from Jan 2019, to update HRIS holdings SSEPS (Payroll) Sustained in some States; but GRSS funds passing through payroll now irregular and of near-trivial value Still in SMo. Hs, Mo. H Directorate of Finance, Mo. LPS Under IMPACT, HRIS set up with payroll, including payment execution management, functionality; consider using this to provide additional assurance on health worker incentive payments, paralleling education IFMIS (Finance) Used and up to date at national Mo. FP, and Mo. H Directorate of Finance interface with it; not consistently used at State level Still in Mo. FP and Mo. H Directorate of Finance and working; in some SMo. Hs Sustain and engage at centre. In the event that, in R-ARCSS context, States are re-consolidated, it is plausible to believe that use of Free. Balance IFMIS could be resumed at SMo. Fs. If not, costs and infrastructure requirement per-seat may be prohibitive for 32+1 State, GRSS may wish to look at “lighter” options that could be used by SMo. Fs, Line Ministries at State level, and Counties, paralleling HRIS. DHIS (health service operations/c urative/ epidemiologi cal data) DHIS 1. 4 instance had been in use at various times and at various scales; anticipated HPF support not arrived; during 2018, UNDP funded establishment of a DHIS 2 instance – but not clear it has any data yet Yes, at Mo. H and reporting staff nationwide Make DHIS 2 work, leverage HPF IP support (and use DHIS 2 in preference to ad hoc spreadsheet M&E), sum of DHIS 2 reporting and SSHI monitoring greater than the parts NIS (Nutrition) Held by cluster rather than Mo. H, but data up to date. Data has now been shared with SSHI team Cluster and IPs to work to ensure Country systems can operate and in due course sustain NIS AIMS Mo. F system that has fallen into desuetude, and is less relevant in the context of reduced aid volumes coming ‘near government’ No longer applicalble Updated December 2018 3

Introduction/Background • The component on information systems mapping in South Sudan is the first of three workstreams of the Health Systems and Facility Mapping Project ( 1. Information Systems Mapping, 2. Donor and Partner Survey, 3. Facility Survey) funded by the European Union (EU), implemented by the Ministry of Health with technical support from Charlie Goldsmith Associates (CGA). • The project seeks to improve the availability, flow and usefulness of information regarding the health system. By seeking to map and understand these, and effectively integrate the key data sources onto the MOH’s website, it is expected that oversight can be strengthened and planning aided by better data availability. • This workstream involves understanding the sector’s information management systems, which support the management, delivery and oversight of services, and the use of public funding. • A number of significant national systems have been established 2005 -, some of which have been sustained, and a subset of those, kept up to date to 2018, but there remain a number of different reporting and monitoring mechanisms outside of these, principally under the control of fund managers; many of which are proprietary, do not link in to national systems, and do not provide transparent data. • The cessation of various projects supporting systems in different sectors, coupled with the effects of conflict, fiscal crisis and administrative changes has progressively impacted the geographic coverage and functioning of key systems 2013 - and even more so 2016 -2018 • This project has provided a basis to support MOH to make progress coordinate the various information sources so that data is visible in one place – the ‘one stop shop’ website dashboard on www. southsudanhealth. info that MOH and partners can see progress on key indicators – but progress has been circumscribed by the extent to which complementary national information systems have no longer been kept up to date • There remain limited incentives for Mo. H to integrate systems as collection of data on the ground by National ministry staff provides incentives for separate data collection exercises; such 4 incentives (per diems etc) have a particular in the context of government salaries being Updatedpull December 2018

Methodology – original 2016 survey • A structured question guide was developed, reviewed, tested and validated in a quorum of MOH team representing (M&E, HR, Nutrition, Finance & Admin. ) and Charlie Goldsmith Associates team • Authorisation Letters were signed by the Undersecretary and distributed to the MOFEP and MOLPS for the exercise to commence • A team of six ( three from Mo. H and three from CGA) was formed • The aim is to have a better understanding of each information system: information flows, how data is collected (what forms are used, who does it? ), how is it managed, who is involved, how is it reported, the current state of its data, coverage, use, and ownership. • The objective is to be able to draw a picture of this, and also understand what the final output looks like • Interviews are conducted as conversations, not surveys, clarifying answers where needed. • A series of consultations and interviews were conducted and results shown in the subsequent slides. • In last quarter of 2018 follow up consultations were held to confirm earlier described systems were still correct, and/or update Updated December 2018 5

Summary of consultations ( 1 / 2): Information System Who was consulted PMIS • • • Dr Moses Malual, DG Pharmaceuticals Dr. Bortel, Executive Director, CMS Dr Neni Daniel Moro Lawrence-LMU Coordinator Sunday Kilara (Distribution Manager- CAIPA) 17/11/16 18/11/16 21/11/16 24/11/16 29/11/16 HRIS – Public Service HRIS - Mo. H • • Akim Alex – Mo. LPS Dr Malek Santo- Senior Inspector Mo. H, HR/HPF 21/12/18 26/10/18 SSEPS • • Akim Alex, Mo. LPS U/S Mo. LPS Mr Tombe Mo. LPS Juan Suzan, Admin/Finance, Mo. H 18/12/18 29/10/18 30/10/18 29/11/18 Updated December 2018 When 6

Summary of consultations (2 / 2): Information Systems Who was consulted When IFMIS • • Paulino Bok Guk, Mo. FEP Ocum Genes (DG Budget MOFEP) 31/10/18 21/11/16 DHIS • • Victor Misaka (MOH Data Manager)/James Wani 10/12/18 Weekly since July 2018 NIS • Qutab Alum (Systems Manager), provided data to James Wani for upload after further consultation Dec 2018 AIMS • Lwiza Deng (Mo. FEP Aid Coordination Office) 23/11/16 Updated December 2018 7

Summary of systems data flow findings updated to Dec 2018 System Means of data collection at lowest level Date of most recent submissions, as reported Number of states /counties reported at most recent submission date Denominator # of reports expected from states / counties Accessed by Mo. H? Accessed by SMo. H? Accesse d by CHD? PMIS Monthly reporting form Nov. 2016 3 counties 79 Y N N HRIS PS Form 40 & Form 1 Sporadic ALL line ministries N N N HRIS Mo. H Data form Dec. 2015 (but in recent sustained use for education 2018) 8 HPF 2 states 79 Y Y Y NIS Data form Nov. 2018 40 partners 40 Y Y N IFMIS Budget template Dec. 2017 10 former states/32 New 10 Y Y Y SSEPS 1 Payroll Jun. 2016 5 former states 6/10 N N N SSEPS 2 Payroll Jun. 2016 3 former states 4/10 N N N DHIS 1 Monthly reporting form Sep. 2018 3 former states 79 Y Y Y DHIS 2 Summary of reports New App system All ten states 79 Not yet Updated December 2018 8

Key Systems Findings Updated December 2018 9

Summary of which organisations developed, fund and support(ed) the systems System Which authority has overall responsibility for the system? Who developed the system? Who provided support to develop the system? Currently operational? AIMS Directorate of Aid Coordination, Mo. FEP Development Gateway UNDP No PMIS Directorate of Pharmaceuticals, Mo. H SIAPS supported by USAID through MSH and now Chemonics is taking over USAID through MSH Yes, but not used HRIS PS Directorate of Human Resources, Mo. LPS&HRD Deloitte USAID; Deloitte Desuetude; last substantial use 2014 HRIS Mo. H Directorate of Planning and Budgeting, Mo. H Charlie Goldsmith Associates HPF donors Yes, and actively used in education NIS Nutrition Cluster; Directorate of Nutrition, Mo. H UNICEF Yes IFMIS Directorate of Budget, Mo. FEP Deloitte World Bank Yes at national level SSEPS 1 Directorate of Human Resources, Mo. LPS&HRD Booz & Company GRSS Yes SSEPS 2 Directorate of HR Management, Mo. LP&HRD DAI; CBTF; STSFE World Bank through DAI No DHIS 1 Directorate of Planning and Budgeting, Mo. H HISP HPF; UNDP; WHO; MSH; Health. Net Partially DHIS 2 Directorate of Planning and Budgeting, Mo. H University of Oslo HPF; UNDP; WHO; MSH; Health. Net; Global Fund Work up phase 10 Updated December 2018

PMIS : Findings (1 of 2) • Current status of system • The system’s name is Logistics Management Unit (because it covers in country logistics of drugs distribution and reporting) • Database operating on a dashboard, sits in MOH premises • Developed by SIAPS through MSH funded by USAID • The system currently captures 15 of the essential primary healthcare drugs • Dashboard data focuses on stock levels and predominately to trace potential stock outs while the main information recorded is if reports have been received • Current status of data • Data received sporadically between June and September 2016 from HPF states. • Data should be collected and reports sent monthly but currently not the case in practice due to creation of now 32 (plus 1) states and lack of infrastructure, and follow up • Last updated on September 2016, for Morobo, Lainya and Kajo Keji. For most States not regularly updated after conflicts last quarter 2016 • No data for Jonglei and Upper Nile • Updates mainly driven through donor funded projects Updated December 2018 11

PMIS : Findings ( 2 of 2) Planned system • To extend the product list beyond the 15 current essential tracer medicines • Plan to integrate the dashboard ARTs, anti-malarials and family planning commodities • Plan to rollout the system to all other states • Mo. H to encourage the pull system as opposed to the push system to ensure accountability How proposed MOH Mapping Dashboard could interface with the system: • Link to PMIS dashboard (most simple) • Show much data has been received/how current • Provide summary data from PMIS on MOH Mapping Dashboard (e. g. place on map where data has been received from, where stock outs have occurred, etc) Updated December 2018 12

PMIS : Data flow as it should be MOH DG Pharmaceuticals & Drug Supplies Quarterly Reports Undersecretary MOH Patients and Stock Reports Server LMU/CMS Drugs & Reporting Tools Referral and State Hospitals Consumption Reports Drugs and Reporting Tools Different Report types & Drug flow County Drugs and Reporting Tools Reporting PHCCs, PHCUs & County Hospitals Updated December 2018 13

PMIS : Data flow as reported MOH DG Pharmaceuticals & Drug Supplies Quarterly Reports Patients and Stock Reports Server LMU/CMS Drugs & Reporting Tools Undersecretary MOH Referral and State Hospitals Consumption Reports No reporting Drugs and Reporting Tools Different Report types & Drug flow County No reporting Drugs and Reporting Tools Reporting Limited reporting through Mo. H system (as of Dec 2016) PHCCs, PHCUs & County Hospitals Updated December 2018 14

HRIS Public Service Current status of system • Access database (online using a server); regular power issues at Ministerial levels • Developed by STSPE with funding from USAID through Deloitte • The system is maintained by Directorate of Human Resource Management, Mo. LPS Current Status of data • Data from system was previously exported into excel for analysis, however functionality not available due to system overload • Data entered at National level, no state or county data entry. No updates due to lack of Technical support (after 2014) Planned system • To expand capacity of the system to be able to withstand overload and still maintain its functionality requiring technical and financial support How MOH Dashboard could interface with the system: • n/a obsolete system Updated December 2018 15

HRIS Public Service: Data flow as reported Undersecretary MOLPS DG HRM Decision on files Staff files Verification Files move back for stamping and signoff HRM Department Files back for entry into HRIS Verification of staff files and numbers Director HRIS Files returned Staff files with allocated Establishment numbers Public Service Data Clerks Staff File with either Form 40 or Form 1 & all relevant credentials All Line Ministries (Establishment Officers) Updated December 2018 16

HRIS – Mo. H: Findings Current status of system - health • Web based database • Data entered at the county ( by CHD HR officers), accessed by SMo. H & Mo. H • Managed by Policy, Planning and Budgeting Directorate, HR department • Data maintained up until December 2015 ( for five HPF former states – EES, LKS, NBG, WRP, and UTY data collected but not uploaded) however not updated since then • Update to Dec 2018: system in at-scale use for education – pilot 2016, national scale 2017 Current status of data • Stores scans of qualifications, training, appointment letters, photo, as well as data on payroll and grading • Health data not updated on the system/web since December, 2015. Allegedly off line updates available through HPF Planned system • HRIS needs to be rolled out in remaining former states (CES, JGL, UNS, WES), and data holdings updated • Reinforce monthly reporting from counties that HRIS was rolled out( updating staff promotions, new staff, staff that have left) • Improved use of proposers and authorisers of changes needed • Some Capacity Building required How Mo. H Dashboard could interface with the system • Link to HRIS website • Reports on how much has been received/how current Updated December 2018 17

HRIS MOH: Data flow as it should be MOH/HR Reporting SMOH/HR Data from the server HRIS Website Data from the server Reporting Data goes to and comes from the server CHD/HR Data on facility Staff PHCCs, PHCUs & County Hospitals Updated December 2018 18

HRIS MOH: Data flow as reported MOH/HR No reporting SMOH/HR Data from the server HRIS Website Data from the server No reporting (as of Dec 2016, Dec 2018) Data goes to and comes from the server CHD/HR Data on facility Staff PHCCs, PHCUs & County Hospitals Updated December 2018 19

IFMIS: Findings Current status of system • Free-balance ( integrated database server) managed by MOFEP • Data should be collected by all states but currently no reporting since 2015 because of changes in the state structure, no STMC and CTMCs and partner support withdrawn Current status of data • No reporting due to changes in state structures, though funds are being transferred to Hospitals, and Counties. • Formerly CTMCs would review data before it was sent ‘up’ to STMC, CTMCs no longer exist and reports are not sent (partners no longer involved in supporting this process) • IFMIS State expenditure reports not regularly shared with Mo. H Planned system • Plan in 2016 had been to expand system to capture information on all 32 (plus 1) states (budgets and transfers), and when GRSS 2017/18 budget is approved, and to roll out training to states ( currently Mo. FEP Technical staff are attending training in Uganda); this was done, but Mo. FP does not have staff (nor capacity) to ensure and follow up regular reporting, nor the resources to support SMo. Fs to operate IFMIS • IFMIS at Mo. FP has been sustained since, and progress has been made on Budgeting processes • Potential for links between SSEPS and HRIS to make IFMIS more comprehensive, including budget preparation and resource management • Need remains to follow up and trace transfers to States, Counties and Service Delivery Units How proposed MOH Mapping Dashboard could interface with the system • Budgets and tracker (for transfers) could be uploaded onto Mo. H dashboard • Reports from States or summary of what has been submitted/ how recent, if SMOFs resumed using an IFMIS system 20 Updated December 2018

IFMIS: Data flow diagram as it should be National Hospitals State Transfers Monitoring Committee (STMC) Local Government Board National Ministry of Finance Ministry of Labour, Public Service & HRD National Ministry of Health SSP County Transfers Monitoring Committee (CTMC) State Ministry of Local Government State Ministry of Finance Health Science Institutes State Ministry of Labour, Public Service & HRD State Ministry of Health State and County Hospitals SSP Local Government Administration Department County Health Department PHCUs Updated December 2018 PHCCs Key: Reports Money/data 21

IFMIS: data flow, as reported Key = currently taking place = not occurring in IFMIS, Dec 2018 – either occurring manually or on various ad hoc systems Updated December 2018 22

SSEPS (1 and 2): Findings Current status of system • SSEPS 2 web based database, SSEPS 1 Access database with reports onto website • Mo. LPS HRM department responsible, with entry by payroll managers and viewed by finance managers in line ministries • SSEPS 2 rolled out in 4 former states of WBG, WRP, EES & CES. • The four states, national hospitals and national ministries were reporting until changes in State structures • The remaining six former states are, as at December 2018, using SSEPS 1, less than in 2016, partly due to irregular salary transfers Current status of data • Reports no longer being sent to centre for both SSEPS 1 & 2 since Sept. 2015 from States due to new state structure and no follow up • Irregular transfers mean payroll not being consistently processed • SSEPS 1 capability has provided durable Planned system • 2014 intent to roll out SSEPS 2 to all ten former states, but no partner support Potential links with MOH Mapping Dashboard • Show much data is captured/how recently • Summary reports on number of workers by job type/grade • SSEPS engagement depends on there being a meaningful volume of funds flowing through a payroll system Updated December 2018 23

Nutrition Information System: Findings Current status of system: • Front end using visual basic (dotnet), back end Access • Developed and managed by nutrition cluster coordination office • Permanent Partners (MOH, UNICEF, WFP, SC, ACF and Cluster coordination) access through cluster central email after data is uploaded by systems manager • 40 nutrition partners maintain monthly reports to an average of 80% reporting Current status of data • Reports on cluster established nutrition indicators monthly as well as daily to track the changing status of malnutrition Recommendations If the information systems cannot be fully integrated, they should be linked to be able to communicate to one another and be able to generate required information and reports All nutrition indicators need to be captured in DHIS 2 as of January 2016 since it currently only captures 3 of the indicators Nutrition focal point person should be identified in M&E to be trained to use DHIS 2 to generate reports on nutrition indicators The nutrition focal point should be linked to Nutrition information system to have access to the central email for nutrition cluster • How system could map with proposed Mo. H Dashboard • Export report from central email on a monthly basis or daily basis with analysis • Reports to show many reports received and how frequently by state/ partner • Summary reports • December 2018 – first export made available, trial upload made Updated December 2018 24

NIS: Data flow as reported Quarterly Reports DG Primary Healthcare Service Undersecretary MOH Weekly updates & Quarterly narrative reports (No statistical data) Director of Nutrition No regular reporting only on request Key Nutrition Cluster partners-WFP, MOH, UNICEF, SC, ACF, Coordination Unit Aggregated Analysed Reports through central email Nutrition Cluster Information Systems Manager Monthly Reports All Nutrition Cluster Partners Updated December 2018 25

AIMS: Findings • Current status of system: • No longer in use, due to system not being user friendly, expensive and not able to be integrated with IFMIS. • Details of system: • Web based system interface on a server hosted in Nairobi • Mo. FEP Directorate of Aid Coordination • Data entered at beginning of 2016 • Donor focal points collect data, systems manager in Aid Coordination analyses and reports, and line ministries view data • Online interface, with feedback sent by email • Future plans: • Plan to develop new system closely linked to IFMIS once funding is available • How proposed MOH Mapping Dashboard could interface with the system: • When new system integrated with IFMIS, summary reports could be displayed on the Dashboard Updated December 2018 26

DHIS: Findings Current status of system • Legacy DHIS 1. 4, Access based, equipment for DHIS 2 distributed • It is managed by the Directorate of Policy, Planning, Budgeting and Research • Data is exported into xml file and shared • Currently Mo. H M&E data manager submits DHIS 1 exported reports to Oslo University (DHIS 2 technical partner) for upload into DHIS 2 • DHIS 2 instance set up with UNDP support, progress of transition not clear Current status of data • There was a significant drop in reporting rate (since creation of additional states), presently reporting picking up • There is weekly submissions for IDSR and the actual reporting is done monthly and quarterly. • Latest reports being received are for July 2018, data collection from SARA might have affected reporting Planned system • To migrate to DHIS 2 next year (web based). Roll out in progress • To solicit funds to support technical capacity, ongoing • To rollout to the states Potential links with MOH Mapping Dashboard • Show much data is captured/how recently • Show information on key health indicators mapped by geography Updated December 2018 27

DHIS : Data Flow Diagram Assumed that DHIS 2 will take place from County by smart phoned based App National MOH State SMOH County CHD DHIS 1. 4 Payam Facility Hard copy Source: South Sudan Conference Presentation. Bloemfontein, South Africa, April, 2015 Updated December 2018 28

Summary: Key Improvement Areas and Links System Key areas for improvement Potential links to be added PMIS • Could be expanded to include information on more of the primary healthcare drugs. At present reporting only done on 15 drugs. Enhanced timeliness of data collection across all areas of the country. • PMIS data incorporated into DHIS 2 to utilise information on drug shortages further informing response to disease outbreaks. Added functionality to aid data analysis and prevent system overload. System expansion to include data at state and county levels as well as national level. • HR public service data to be linked with HRIS Mo. H (as below) to create HR health data repository. HRIS public service to link to DHIS 2. Enhanced timeliness of data collection – monthly reporting. Data collection rolled out across all areas of the country and at CHD/ SMOH/NMOH levels. • • HRIS – Pubic Service • • HRIS - Mo. H • • HRIS data inked to SSEPS payroll system would streamline health salary payments. HRIS Mo. H to link to DHIS 2. SSEPS (1 and 2) • Reporting across all states for 32 state system and uniformity of SSEPS 2 across partners. • Link to HRIS Mo. H (as above) IFMIS • • Reporting established to 32 state system. Expand system to capture all financial information on budget and transfers • Link to SSHI transfers section to enhance and overlap information on transfers • Link to DHIS 2, financial information captured as part of reporting. DHIS (1. 4 and 2) • • DHIS 1. 4 to be upgraded to DHIS 2. Requirement that data incorporated into DHIS 2 is uniform across 32 state system and has timely reporting. Roll out DHIS 2 (once established) to a state/ county level to allow use of and interpretation of health data. • Information incorporated onto DHIS 2 from: PMIS, HRIS Pubic Service, HRIS Mo. H, IFMIS and NIS. • NIS • NIS access/ reporting made accessible across MOH departments (currently maintained partners). • All information to be linked to DHIS 2 AIMS • System no longer in use and not able to integrate DRAFT with IFMIS. Updated December 2018 • Integration with/ replaced 29 by IFMIS.