By Emmanuel Timothy THWOL

PhD candidate, University of Juba


Health services and health systems management ,strengthening or development initiatives are influentially emerging as true interdisciplinary approaches of inquiry where ideas from many different perspectives are combined into conceptual frameworks to address health system problems in terms of services satisfactory ;its efficiency and effectiveness . One of the key challenges to these developments is difficulty in resolving misunderstandings of shared terminology and methods of evaluation of health indicators upon the recipient of healthcare services, furthermore most problematic words that I will assert here and it has never been understood in its context as far as health system performance is concern is ‘efficiency’. This paper will document some of the attempts to assesses and evaluate the efficiency in health care and illustrate circular reasoning and of the existing healthcare system in Upper Nile State , especially in trying to understand health care operationalization , performance ,inputs, innovation and its impact in enhancing health indictors . The driving motivation of the paper is to try to point a way forward and innovating batter approaches to boost, improve and advancements in health services and health systems for the ultimate benefit of healthcare’s receivers in the state.

Keywords: efficiency; innovation; health system; healthcare; performance; health indicators.


Asystem can simply be defined as a group of interdependent items that interact regularly to perform a task. The essence of a system is the interaction of items in order to achieve a defined goal. A health system, also sometimes referred to as health care system or healthcare system is the organization of people, institutions, and resources to deliver health care services to meet the health needs of target populations.

Thus, a health system is not merely a collection of discrete services each being delivered without specific relationship to the other elements of health care. It consists of all organizations, people and actions whose primary intent is to promote, restore or maintain health (WHO 2000). This includes efforts to influence determinants of health as well as more direct health-improving activities.

A health system is therefore more than the pyramid of publicly owned facilities that deliver personal health services. It includes, for example, a mother caring for a sick child at home; private providers; behaviour change programmes; vector-control campaigns; health insurance organizations; occupational health and safety legislation. It includes inter-sectorial action by health staff, for example, encouraging the ministry of education to promote female education, a well-known determinant of better health. (WHO, 2007). It is a fairly complex system of inter-related elements that contribute to the health of people - in their homes, educational institutions, in work places, the public (social or recreational) and the psychological environments as well as the directly health and health-related sectors. (Asuzu,2004).

The challenge in developing a health system is to organize the various elements for health promotion, specific disease prevention, diagnosis and treatment of ailments and rehabilitation. The required inputs include biomedical interventions as well as contributions from other relevant sectors.

Health system performance assessment boasts of nine dimensions incorporated in this study , namely: (a) effectiveness; (b) appropriateness; (c) efficiency; (d) responsiveness; (e) accessibility; (f) safety; (g) continuity; (h) capability; and (i) sustainability. This part of the performance framework poses the question: ‘How well is the health system performing in delivering quality health actions to improve the health system, the evaluation of system-wide performance from population benefiting for the services, health programs in both aspects preventive and curative, primary care, secondary health care, and continuing care services, thus reflecting the four main sectors in the health care continuum of South Sudan.

The selective and still developing national indicator sets that populate this framework may in some areas span more than one domain of performance. Development work on the indicators hopes to achieve an operationalization of the inputs, outputs, and outcomes model along various performance domains, while paying particular attention to national priority areas and targets opted.

Problem defined

The health system in Upper Nile State faces sever inefficient and ineffective coordination of health inputs and management at curative and preventive intervention, which is manifested in a fragmented and unfortunate non consistent presentation of health indicators”.

Statement of the Problem

The purpose of this paper is to assess, compare, contrast and determine the variables that explain the importance of effective and efficient health system management and how it affects health systems performance, defining its impacts on variable health indicators across health system building blocks in Upper Nile State

Analytical methods

The health-systems performance assessment framework used in this study was based on WHO’s norms for the health system building blocks. The analyses covered all aspects including inputs (financing, human resources, information, and governance), outputs (service readiness), outcomes (coverage of interventions and prevalence of risk behaviours), and effect. The effect was measured according to WHO’s intrinsic goals for the health system achievement of equity in health outcomes, and fairness in financial contribution and responsiveness, additionally the health system building blocks elements were subjected for further assessment of its Analysis of Strengths, Weaknesses, Opportunities and Threats (SWOT) to identify the resilience of the current health system. Time trends were assessed and results were compared with other regional countries health system performance . Data for the analyses were obtained from a range of sources. Comparisons with earlier surveys enabled an assessment of time trends and subnational analyses.

Furthermore, we do acknowledge the shortcomings of this study’s methodology and other relevant hesitations, which were due to circumstances in which this assessment was conducted. Deferent information sources were utilized to complete this study to safeguard exclusiveness and comprehensiveness of the information presented in the study.

Summary of study findings

In the assessment of core activities and supportive functions of the health System (healthcare) in Upper Nile State , the study found that the existence /knowledge of the health system as a conceptual idea is premature at all levels of the health system in state as far as the structural hierogram is concern . However the information collected about implementation and operationalization of the health system upon the recommendable standardized manner is below 60% at all levels. Data analyses considering health system building blocks indicating the existing healthcare performance were far below the recommended standard and that is manifested in poor indicators presented at annul SMOH bulletins .Must of the assigned healthcare staff members had been trained at deferent levels with deferent curriculums and applying numerous standers. Lower levels of the healthcare such as Primary Health Care Centres and Units lacked modern technologies for service delivery. The health system in Upper Nile state is categorized as a decentralized system; Moreover, the system has not been updated on system operation and management, at some healthcare levels poor documentation of services delivery profile, shortages, recommendations for betterment, stock file and epidemiological trend follow-up are impossible to be tracked.


This paper presents comprehensive assessment results, to the best of our knowledge, of the performance of the health system in Upper Nile State. The assessment of health-systems performance was hampered by many gaps in availability and quality of the data. Reliable data from various healthcare levels, trends, and equity for many key indicators were missing or insufficient. For instance, Upper Nile State does not have a functioning civil registration and vital statistics system; a health examination survey has not been undertaken since independence of South Sudan; and national health accounts have been assessed. No reliable subnational data exist for the health workforce and data for the availability and quality of services are lacking. The gaps in data restricted our ability to undertake an analysis of the county for most indicators or draw firm conclusions about the effect of specific policies on coverage or health outcomes.

All available quantitative and qualitative data were evaluated to build a comprehensive picture of the current situation and trends in the past decades. The interpretation, however, had to be subjective at times to be able to present a comprehensive picture of the health system in Upper Nile State. We have aimed to be cautious and clear about our interpretation of fragmentary evidence.

Despite these limitations, in this analysis we have identified many priority gaps that need to be addressed in terms of information and analysis to better inform policies and reforms. More importantly, the analysis shows that Upper Nile State’s health system has been unable to achieve some goals of adequate and equitable health status, fairness in financing, and responsiveness. The analysis has also drawn attention to actions that are needed to make the best improvements in each of the domains of health systems.

There were also the issue of vagueness and questionable reliability of data presented in the course of the study which has been addressed and data are scrutinized through verification scientific means before authentication and circulation as a reference document in health system reform, leaving a very narrow room for speculation as to the true implications of policies and terms.

Contributions of the private sector, community and other health stockholders are highlighted as an important aspect of boosting health system performance, as all the study bodies frequently suggested some actions and recommendations to updated such as practise, skills, knowledge and promote operational issues in the short and long scope.

The paper has shown that building block specific weaknesses had cross cutting effect in other health system building blocks which is an essential element of systems thinking. These linkages emphasis the need to use system wide approaches in assessing the performance of health system interventions. It was clear that challenges noted in services delivery were linked to human resources, medical supplies, information flow, governance and finance building blocks either directly or indirectly.

Nevertheless, much effort has been spent to eschew these potential biases, by being thorough and objective. This study analyse stepwise: the various conceptual bases, effectiveness as a concept, the resultant proxy roles and responsibilities, services delivery, resources utilization, health indicators performance and management healthcare system and health services, other operationalization issues surrounding indicators of effectiveness, the quality effectiveness relationship, the mechanism of change and briefly, the idea of ‘performance environment’ of the health system in the Upper Nile State.


The current drive to strengthen health systems provides an opportunity to develop new strategies that will enable SMOH to achieve targets for millennium development goals. The status quo of public health interventions have been criticised as too narrow and implemented in piece meal fashion, lacking comprehensiveness and whole-system perspective. This compartmentalized approach is said to be engrained in the financial structures, intervention designs and evaluation methods of most health agencies. In recent time, it has been acknowledged that conventional analytical methods are generally unable to satisfactorily address situations in which population needs change over time often in response to the interventions themselves.

Hence this paper is looks for ways to evaluate, monitor and reform the performance of health systems. Various attempts have been made to come up with common frameworks to guide health system assessment. At different times, this paper will been bring forward and often acts as the basis for the next generation of health system frameworks assessment. It emphasized that most of the frameworks describe the normative approaches and have little to do with what actually happens on the ground in the area of the study. Nonetheless, I am providing a strong theoretical foundation for conceptualising health systems and a start point to strengthen the weak health system in Upper Nile State as a sample of intervention of study for the whole South Sudan health system structure as far as health system reform is concern.

This paper generalizes in five specific study questions across this thesis which could be summarized in the following points:

  • Indicators could be used for marking the performance of a strengthened health System.

  • The effect of the impacts of basic health package services intervention on the health system indicators in Upper Nile State.

  • Important processes, contextual and system factors that could explain the observed changes and enhance the system’s performance.

Way forward

The intent of this paper is to be hypothesis generating and bases of helping to improve conceptual frames of health system, its impact on the health indicators, by underlining some important system problems in the study across disciplinary frameworks of health system building blocks. The attempt is to make the key issues more transparent, to identify the threats and weakness points and contribute so as to leave behind some touch on health systems research and health services research especially in evaluation of South Sudan healthcare. The superseding emphasis is the definition opportunities and strengths to enhance quality, efficiency of the healthcare services provided within our health system and therefore increasing accesses to health facilities .And an effective Updating Mechanism of the information and follow-up be launched and commence it activities regularly at SMOH level and sub committees should be formed at counties CHDs to ensure that health system reform are made and the recommended alterations are implemented at all health system level.



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