CONTRACTING-OUT OF PRIMARY HEALTH CARE SERVICES IN CONFLICT-AFFECTED SETTINGS: THE CASE OF SOUTH SUDAN

South Sudan introduced a nation-wide geographically focused contracting approach with funding from 3 main donors, to rapidly scale-up access to health services starting mid-2012. The overall aim of the thesis is to assesses its effect and impact on maternal and child health. In the first paper, I provide extensive background on the history of health services delivery in South Sudan prior to assessing progress in increasing health facility utilization among women and children under-five, using routine health facility data. I thus compare the period (2011-2013) to the policy period (2013-2015) at national and sub-national level using Prais-Winsten and Cochrane-Orcutt regression and find significant increases in health facility utilization. Given the overall increase in health facility utilization, the second paper assesses impact of the policy on child mortality using a novel approach to construct a synthetic South Sudan from a panel of lower- and middle-income countries (LMICs), and using data from the World Bank Developmental Indicators (WDI) database. The analysis shows that on average, contracting out had a negative effect on the rate of decline of U5MR during the policy period. These findings suggest limitations in the approach implemented in South Sudan. The third paper further evaluates the contracting intervention by evaluating three contracting approaches in Jonglei and Upper Nile States; contracting-out (C-O) using non-governmental organizations (NGOs), contracting-in (C-I) using county health departments (CHD) and performance-based contracting (PBC) in select counties. Using difference-in difference (DD) and DD with propensity score matching. I hypothesized that contracting-out to NGOs leads to higher performance relative to contracting-in with CHDs, that performance-based contracting incentivizes health workers, hence PBC counties have higher utilization relative to non-PBC counties. Results are not as straightforward; there are no significant differences in the double differences for ANC 4th visits, health facility deliveries, DPT 1, DPT 3 and diarrhoea. Additionally, PBC had no effect on utilization relative to counties where there was no PBC incentive