1 ACKNOWLEDGEMENTS We would like to extend our appreciation to all the individuals, organizations, and institutions who provided their knowledge and expertise to the development of this report. This report was prepared by World Bank staff with contributions from partners and collaborators. This report is the result of the dedicated efforts of a committed research team. We would like to extend our sincere gratitude to Garang Buk Buk, Kent Garber, and Isha Nirola for their invaluable contributions to the research and preparation of this report. We are especially grateful for the guidance and supervision provided by Amr Elshalakani and Annie Liange, whose leadership and expertise were instrumental throughout the process. The report was reviewed in its draft form by the following peer reviewers: Tseganeh Amsalu Guracha (Senior Health Specialist, HAEH1), Abdisalam Ahmed Bahwal (Health Specialist, HAEH2), and Ayodeji Gafar Ajiboye (Senior Economist, HMNHN). We appreciate their thoughtful support and feedback. We would also like to acknowledge the support of our Country Management Unit, led by Charles Undeland, whose direction and encouragement were essential to this work. Special thanks are due to our Practice Manager, Ernest Massiah, for his ongoing support and oversight. We also express our deep gratitude to Jessica Flannery, Shafali Rajora and Miyuki Parris for their technical and operational guidance. The development of this analytics report was supported by the Japan Policy and Human Resources Development Fund (PHRD) Trust Fund, financed by the government of Japan. We are deeply grateful to the PHRD Trust Fund and the government of Japan for its support of this report. Our collective efforts have made this report possible, and we are appreciative of everyone’s commitment and collaboration. 2 TABLE OF CONTENTS SUMMARY OF MAIN FINDINGS...........................................................................................................5 BACKGROUND....................................................................................................................................6 INTRODUCTION .................................................................................................................................6 OBJECTIVE .........................................................................................................................................7 METHODOLOGY .................................................................................................................................7 LIMITATION........................................................................................................................................7 FINDINGS...........................................................................................................................................8 HEALTHCARE WORKERS MOTIVATIONS AND PREFERENCES ..................................................................8 ACCOUNTABILITY MECHANISMS FOR RURAL HEALTH WORKERS AND THE HEALTH SYSTEM ................. 10 SUPPORTIVE SUPERVISORY PRACTICES ................................................................................................................. 10 SALARY DISBURSEMENT .................................................................................................................................... 11 HEALTH WORKERS RECRUITMENT, PERFORMANCE, AND RETENTION ................................................. 11 RECOMMENDATIONS ....................................................................................................................... 14 HEALTH WORKER RECRUITMENT/DEPLOYMENT ................................................................................ 14 HEALTH WORKER PERFOMANCE/RETENTION .................................................................................... 16 ANNEX............................................................................................................................................. 18 3 Acronyms CHD County Health Department CHW Community Health Worker CSO Civil Society Organization BHW Boma Health Worker FCV Fragile, Conflict & Violence HCW Healthcare Workers HRH Human Resources for Health INGO International Non-governmental Organization KII Key Informant Interviews LMIC Low and Middle Income Countries MOH Ministry of Health ODK Open Data Kit QOC Quality of Care SDG Sustainable Development Goals UHC Universal Health Care UN United Nations UNICEF United Nations Children’s Fund WHO World Health Organization 4 SUMMARY OF MAIN FINDINGS Preferences among rural health workers for improving their motivations include a series of non-financial incentives alongside financial compensation. Some of these incentives include transportation stipends and increased telecommunication access, noting a higher need for mobility and connection among those operating in remote settings. Alongside personal benefits, health workers highlighted the need for improved facility conditions, including improvements in structural capacity and security. Supportive supervision and community oversight are key components of accountability in South Sudan’s rural health system, but implementation is hindered by logistical and systemic barriers. A combination of national authorities, county health officials, and facility in-charges maintain routine supervisory visits to rural health facilities, while community-led Boma health committees provide oversight in inventory integrity and facility performance. Additionally, a complaint reporting mechanism is functional for both health workers and community members in these rural settings. Though this system is welcomed by health workers, tensions regarding best practices between them and community members persist, largely driven by inadequate facility capacity or supply shortages. Furthermore, the supervision in-place largely focuses on administrative review only within the scope of donor requirements and is limited by inadequate tools and transportation barriers (i.e., insecurity, road conditions). South Sudan faces a critical shortage of health workers, with only about 8,700 deployed against a need exceeding 26,000 to meet basic healthcare goals. This gap reflects not only numbers but deep structural challenges, including very low tertiary enrolment (under 1%), poor secondary school completion (17%), and a mismatch between educational outputs and health sector needs. Barriers such as high tuition costs, limited training centers concentrated in urban areas, and socio-cultural norms particularly restrict women’s participation. Additionally, the proliferation of unregulated private training institutes compromises educational quality, with rural areas disproportionately affected by these systemic weaknesses. Recruitment and retention are further hindered by inconsistent standards and poor working conditions, especially in rural settings. Community-based selection of health workers often overlooks formal criteria like education and language proficiency, leading to the deployment of inadequately trained personnel. Rural health workers face irregular pay, lack of housing, poor infrastructure, insecurity, and insufficient clinic resources, which contribute to absenteeism and attrition. Accommodation near facilities emerged as a critical factor for retention, with many workers expressing frustration at working in under-resourced, isolated environments without career support or supervision. Despite health workers noting social responsibility as a driving factor to commit to serving long-term, insufficiently fulfilled incentives and substandard conditions erode their willingness to stay. Performance issues stem from systemic gaps beyond clinical skills, including irregular salaries, lack of supplies, and absent mentorship or supervision. Career progression opportunities are limited, with unclear roles and scarce refresher training, particularly for rural staff. Informal recruitment practices based 5 on tribal ties rather than qualifications undermine professionalism. Addressing these challenges requires a holistic, community-focused approach that integrates recruitment, training, and deployment with local realities and emphasizes improved working conditions, support systems, and clear career pathways to stabilize and grow South Sudan’s health workforce. BACKGROUND INTRODUCTION South Sudan continues to grapple with severe health system challenges shaped by decades of conflict, political instability, and underdevelopment. Despite gaining independence in 2011, the country has remained one of the most fragile and conflict-affected globally.1 The health sector is particularly strained, with some of the world’s highest maternal and child mortality rates and an acute shortage of skilled health workers. These systemic deficiencies are compounded by inadequate infrastructure, limited fiscal space, and a fragmented service delivery model reliant on donor financing and NGO implementation.2 The human resources for health (HRH) crisis in South Sudan is characterized not only by low workforce density – 0.15 doctors and 0.2 midwives per 10,000 people – but also by significant geographic disparities.3 Most qualified health professionals are based in Juba or in the urban-centered private sector, leaving the predominantly rural population (80%) with inadequate access to a basic level of healthcare. Indeed, health workers in rural and remote locations face multiple barriers to retention and performance, including low and inconsistent pay, poor supervision, professional isolation, and insecurity. These gaps are compounded by the effects of COVID-19, which has further strained an already fragile health workforce.4 Addressing this HRH gap is critical for progress toward achieving Universal Health Coverage (UHC) health-related SDGs.5 However, effective policy responses require a clearer understanding of the motivational drivers and accountability mechanisms that shape health workers’ behavior, particularly in rural and underserved areas. To date, limited data exist on the incentives that matter most to health workers in South Sudan’s unique operating context or on the oversight modalities that are both feasible and impactful in fragile environments. OBJECTIVE This study seeks to fill this gap by exploring the motivational preferences and accountability mechanisms that influence health worker performance and retention in rural South Sudan. It aims to identify practical, context-appropriate approaches to strengthen health service delivery in underserved areas. The findings aim to inform HRH reforms led by the Ministry of Health and development partners. Specifically, the research aims to (i) assess health worker preferences for rural postings; (ii) explore context- 1 World Health Organization, “WHO Delivering Results and Making an Impact: Stories from the Ground.� (Geneva: World Health Organization, 2022). 2 KIT Institute, “Access to Health Care in South Sudan: A Qualitative Analysis of Health Pooled Fund Supported Counties.,� 2020. 3 World Bank, “Rural Population (% of Total Population) - South Sudan | Data,� data.worldbank.org, 2018. 4 EQUAL Research Consortium, “Examining Maternal and Newborn Health Policy, Practice, and Financing in South Sudan - Healthy Newborn Network,� Healthy Newborn Network, November 11, 2024. 5 Colin Gilmartin, David Collins, and Alfred Driwale, “The Boma Health Initiative Costing and Investment Case Analysis,� 2019. 6 appropriate and effective ways to promote accountability mechanisms within South Sudan’s resource- constrained environment; (iii) identify which incentives would encourage health workers to remain and perform in rural areas. The report provides evidence-based recommendations to guide the design of effective incentive structures and accountability models that support a more sustainable, motivated, and equitably distributed health workforce in pursuit of UHC. METHODOLOGY This study employed a combination of a systematic literature review and qualitative key informant interviews (KIIs) to examine health worker motivation, performance, and accountability in rural South Sudan. The methodology was designed to triangulate data across sources to ensure a contextually grounded and evidence-informed analysis. The core of the analysis is a systematic literature review, structured around the study’s three thematic components. A Boolean search strategy was developed using mapped keywords aligned with the study’s analytical framework. The search focused on peer-reviewed literature published within the five years preceding this report (from January 1, 2020, onward) to ensure relevance and contextual applicability. While a subset of the literature focused specifically on South Sudan, the review also included studies from low- and middle-income countries (LMICs), particularly in Central and East Africa, as well as fragile, conflict- affected, and vulnerable (FCV) settings. The search was applied to three databases: PubMed (136 results), Scopus (10), and Google Scholar (44), yielding 190 studies in total. Following a multi-stage screening process, 39 sources were selected for the final in-depth review, 16 of which either focusing on South Sudan or including it in a multi-country study (See Figure 1 in the Annex for PRISMA flow diagram). In addition, 11 grey literature sources were included to provide supplementary context, particularly regarding the South Sudanese health system. The qualitative data includes 13 KIIs to contextualize and supplement the desk review findings, as well as to provide more direct insight into health worker motivations and their perspectives on accountability and steps needed to better retention. The research team conducted five interviews with frontline health workers serving in rural areas. In addition to the field-based interviews, a distinct set of eight high-level remote interviews with health sector leaders in Juba (e.g., UN agencies, INGOs, MoH) was conducted by the World Bank team. These interviews, carried out separately from the five KIIs undertaken for this study, offer complementary perspectives that help contextualize and enrich the analysis. Overall, the interviews explored practical dimensions of workforce motivation, accountability, and deployment, helping to validate literature findings and offer operational considerations specific to South Sudan’s health landscape. LIMITATIONS This study acknowledges some limitations that may affect the generalizability and depth of its findings. Efforts were made to minimize bias during the literature screening process, including independent assessment by two reviewers and the application of clear inclusion criteria. However, reliance on available literature means that certain contextual nuances specific to South Sudan may be underrepresented, particularly given the limited number of recent studies focused solely on the country. For example, only one peer-reviewed source regarding accountability modalities in the South Sudanese health system was identified for the analysis. The inclusion of studies from broader LMIC and FCV settings introduces variability in context that, while informative, may limit applicability to South Sudan’s unique environment. 7 help address this, the qualitative component was integrated to anchor the broader findings in context- specific realities. While no language restrictions were applied, the review ultimately included only English- language publications due to translation constraints, which may have overlooked literature published in other commonly used languages in LMICs. Moreover, due to security and logistical concerns in South Sudan, the study was conducted within a compressed timeline, which required scaling down certain methodological components, including the number of key informant interviews. Indeed, the qualitative component is based on a relatively small sample of 13 KIIs, which may not validly capture the full diversity of perspectives across rural health workers and introduce a certain degree of respondent bias. Nonetheless, the interviews are intended to complement the literature review by providing context-specific insights rather than serving as a representative dataset. Finally, given the rapidly evolving health and security environment in South Sudan, the findings represent a snapshot in time and may require updating as conditions change. Despite these limitations, the combined desk review and qualitative data provide a solid evidence base to inform HRH policy in South Sudan. FINDINGS HEALTHCARE WORKERS MOTIVATIONS AND PREFERENCES Despite having differing reasons for entering the profession, rural health workers see themselves remaining in their posts long-term, motivated by a sense of social responsibility. Some of the reasons the interviewed rural health workers (HCWs) took up their posting in a remote setting either out of passion for the work, to expand their medical knowledge and practices, or due to limited job opportunities in the sector.6 However, one HCW noted that the government deployed them without their input in location preference.7 Still, when asked if these health workers see themselves working in rural settings, almost all of them affirmed this, mainly by a commitment to service these communities and partially due to the lack of new staff coming in.8 As one HCW noted: “What motivates is the need to serve the communities who are far from towns, bringing the services closer to them.�9 Preferences regarding rural health workers’ ability to serve center around improvements to facility infrastructure and health transportation. Every interviewed rural HCW highlighted how imperative sufficient health resources are for the provision of good-quality services to the community. A primary resource brought up includes expanded ambulance capacity at Primary Health Care Centers (PHCC), as HCWs noted their availability only at county hospitals. Presently, the operation of the existing fleets is disrupted by lack of fuel and breakdowns, slowing the emergency response in rural locations.10 Two HCWs also expressed frustration about the limited facility space, with one of them saying, “They construct only two rooms which are not enough. They are supposed to have at least 4-5 rooms.�11 Additional structural improvements cited include expanded availability of health services, sufficient utilities (i.e., water and 6 KII with Rural HCW, Kapoeta South, Int. 1; KII with Rural HCW, Kapoeta South, Int. 2; KII with Rural HCW, Renk County, Int. 4; KII with Rural HCW, Torit County, Int. 5. 7 KII with Rural HCW, Geiger Payam, Int. 3. 8 KII with Rural HCW, Kapoeta South, Int. 1; KII with Rural HCW, Kapoeta South, Int. 2; KII with Rural HCW, Renk County, Int. 4; KII with Rural HCW, Torit County, Int. 5. 9 KII with Rural HCW, Kapoeta South, Int. 2. 10 KII with Rural HCW, Kapoeta South, Int. 1. 11 KII with Rural HCW, Kapoeta South, Int. 1 and KII with Rural HCW, Renk County, Int. 4. 8 electricity), improvements in WASH facilities, and security fencing.12 These issues have been raised or acknowledged previously, as they have been mentioned by health leaders in South Sudan as indicative of a broader funding challenge.13 Additional preferences to improving health worker operability include sufficient medical supplies, as the lack of these resources contribute to declining morale among rural HCWs. These facilities procure their replenished medical supplies every 3-4 months.14 Despite these scheduled procurements for essential supplies, rural facilities are likely to see their inventory depleted rapidly due to increased demand, contributed by the few numbers of facilities available in the vicinity.15 The influx of displaced persons by existing conflicts also overwhelms rural health capacity, limiting the performance of rural HCWs. One rural healthcare worker (HCW) in Geiger Payam – near the border with Sudan – highlighting how refugees from the Sudan conflict has led to quicker stockouts before the next consignment arrives.16 Because of the overwhelming utilization level compared to the number of supplies available, this can undermine the facility’s capacity to provide essential services to the community. This, in turn, can erode community trust in rural HCWs’ capabilities, with some accusing HCWs with misappropriating resources or incompetence.17 As one rural HCW noted: “Inadequate supplies cause the community members to think health workers are not doing their jobs properly.�18 Rural health workers noted preferences for key non-financial incentives alongside financial compensation to support morale. While financial incentives may seem to be a clear way to boost job uptake among rural HCWs, studies conducted in similar LMIC contexts indicated that carefully designed combinations of non-financial incentives (NFI) can yield better results than modest salary increases.19 20 In the context of South Sudan, these NFIs requested include improved staffing accommodations (i.e., boarding), telecommunication access, transportation stipends, and medical insurance.21 Addressing these requests would be able to substitute the low salary that these workers as a driving motivator for performance and retention. Tribal affiliations and language do not appear to significantly influence rural health worker willingness to work in different areas. While communal violence along ethnic and tribal lines by regional militias continue persist around South Sudan, this tension does not seem affect the attitudes of rural HCWs of different tribal backgrounds.22 The community does not necessarily associate the rural HCWs with their tribes, as the community is aware of their roles as service providers.23 Additionally, while health workers noted that they might not know the language of the community they operate in (i.e., Bari, Nuer, Dinka), they receive interpretation support from local auxiliary staff to communicate with service users.24 Despite 12 KII with Rural HCW, Kapoeta South, Int. 1; KII with Rural HCW, Kapoeta South, Int. 2; KII with Rural HCW, Renk County, Int. 4; KII with Rural HCW, Torit County, Int. 5. 13 KII with Health Leader, Juba, Int. 1; KII with Health Leader, Juba, Int. 2; KII with Health Leader, Juba, Int. 6. 14 KII with Rural HCW, Kapoeta South, Int. 1; KII with Rural HCW, Kapoeta South, Int. 2; KII with Rural HCW, Geiger Payam, Int. 3. 15 KII with Rural HCW, Kapoeta South, Int. 1. 16 KII with Rural HCW, Renk County, Int. 4. 17 KII with Rural HCW, Kapoeta South, Int. 1; KII with Rural HCW, Geiger Payam, Int. 3. 18 KII with Rural HCW, Kapoeta South, Int. 1. 19 Julius R. Migriño, “Work Preferences in Rural Health Job Posting among Medical Interns in a Lower Middle -Income Country— a Discrete Choice Experiment,� Central Asian Journal of Global Health 9, no. 1 (July 31, 2020). 20 Margaret E. Kruk et al., “Rural Practice Preferences among Medical Students in Ghana: A Discrete Choice Experiment,� Bulletin of the World Health Organization 88, no. 5 (2010): 333–41. 21 KII with Rural HCW, Kapoeta South, Int. 1; KII with Rural HCW, Kapoeta South, Int. 2; KII with Rural HCW, Geiger Payam, Int. 3; KII with Rural HCW, Renk County, Int. 4; KII with Rural HCW, Torit County, Int. 5. 22Human Rights Division – UNMISS, “Annual Brief on Violence Affecting Civilians: January – December 2024� (UNMISS, 2025). 23 KII with Rural HCW, Kapoeta South, Int. 2 and KII with Rural HCW, Torit County, Int. 5. 24 KII with Rural HCW, Kapoeta South, Int. 1; KII with Rural HCW, Kapoeta South, Int. 2; KII with Rural HCW, Renk County, Int. 4. 9 this, some Health workers acknowledged that personal preconception can deter some individuals from working in areas dominated by other tribal groups.25 ACCOUNTABILITY MECHANISMS FOR RURAL HEALTH WORKERS AND THE HEALTH SYSTEM Supportive Supervisory Practices National authorities, county health department (CHD) officials, and facility in-charges conduct periodic monitoring visits to assess the operation of rural facilities and provide supportive supervision. The primary accountability modalities in-place include integrated supervision and monitoring visits, conducted at varying intervals by different supervisory entities.26 These visits can take place multiple times per week, monthly, or bimonthly, depending on the county and respective authority.27 Among the rural health workers, these supervisions are viewed positively to ensure smooth operations at their respective rural health facilities.28 Alongside national and county health authorities, community-led Boma Health Committees play a role in the accountability of the rural health system. Comprised of mainly traditional leaders, these committees monitor the arrival of medical supply consignments and are responsible for alerting authorities if they detect any malpractice, misuse or diversion of resources.29 Their involvement, however, might cause tension between them and health workers. As one HCW commented, “In all the health centers, community members tend to accuse health workers of misusing health facility resources, even without any proof. The health center authorities raised a complaint with the county health department.�30 This dynamic points to an inherent distrust between the community and the health workers regarding the how these facilities should operate, given the context of limited supply availability. Additionally, these health facilities maintain a complaint reporting mechanism (CRM) for both rural health workers and community members. All five interviewed HCW described an existing chain of complaint channels, starting with the complainant raising concerns to the facility in-charge, who, if unable to resolve it, escalate the issues to higher authorities, up to the national health authorities. Furthermore, these Health workers expressed confidence in their ability to report misconduct at their facilities.31 These CRMs are also accessible to the public, allowing them to voice their complaints. As one HCW noted: “[Rural health centers] get complaints through suggestion boxes, complaints desk, as well as community feedback mechanisms where community members are able to raise their complaints.�32 The CRM do not only promote accountability but also empower both staff and community members to actively participate in improving service delivery. Despite the systems in place to ensure supportive supervision and monitoring, the depth of the supervision and actions taken from their findings are not as substantive. The supervision practices 25 KII with Rural HCW, Kapoeta South, Int. 2 and KII with Rural HCW, Renk County, Int. 4. 26 George William Lutwama et al., “Health Services Supervision in a Protracted Crisis: A Qualitative Study into Supportive Supervision Practices in South Sudan,� BMC Health Services Research 22, no. 1 (2022): 1–16. 27 KII with Rural HCW, Kapoeta South, Int. 1; KII with Rural HCW, Renk County, Int. 4; KII with Rural HCW, Torit County, Int. 5. 28 KII with Rural HCW, Kapoeta South, Int. 1; KII with Rural HCW, Kapoeta South, Int. 2; KII with Rural HCW, Geiger Payam, Int. 3; KII with Rural HCW, Renk County, Int. 4; KII with Rural HCW, Torit County, Int. 5. 29 KII with Rural HCW, Geiger Payam, Int. 3 and KII with Rural HCW, Renk County, Int. 4. 30 KII with Rural HCW, Geiger Payam, Int. 3. 31 KII with Rural HCW, Kapoeta South, Int. 1; KII with Rural HCW, Kapoeta South, Int. 2; KII with Rural HCW, Geiger Payam, Int. 3; KII with Rural HCW, Renk County, Int. 4; KII with Rural HCW, Torit County, Int. 5. 32 KII with Rural HCW, Kapoeta South, Int. 1. 10 conducted focus more so on health administration rather than clinical practices. Furthermore, the findings of these supervisions are often ignored due to lack funding, especially when recommendations involve issues not covered by donor funding. The use of paper-based checklists for these visits can create backlogs that might complicate the feedback review process, making it time-consuming and inefficient.33 Other challenges impeding supportive supervision activities include insufficient reliable transportation and insufficient tools. Compounded by insecurity and poor roads, these activities sometimes necessitate the use of air transport to travel from Juba to other states.34 Monitoring visits carried out by the County Health Departments (CHD) are also susceptible to disruptions due to transportation challenges. As one HCW noted, “The CHD effectively supervise the centers although sometimes they don't come probably due to transportation issues. Otherwise, they always ensure that monitoring is done.�35 Lack of tools such as stationery for printing checklists and tablets for Open Data Kit (ODK) or Quality of Care (QoC) mobile applications also presents logistical difficulties in carrying out supervision activities.36 These combined logistical and resource-related barriers significantly hinder the consistency and effectiveness of supportive supervision, ultimately impacting accountability in rural health settings. Salary Disbursement Implementing partners – not the South Sudan Ministry of Health – compensate rural health workers via financial incentives in cash. Government-allocated salaries to overall Health workers – regardless of urbanicity – is severely limited due to budget restrictions and local currency depreciation.37 As such, most rural health workers do not rely on a government payroll, instead serving as volunteers.38 In lieu of government salaries, health workers receive their compensation from financial incentives in cash by different donor-led health initiatives, implemented by partnering NGOs on a monthly basis.39 Disbursements of financial incentives have been inconsistent and delayed. Interviews with both rural Health workers and health leaders have noted irregular or delayed disbursements.40 There were prior programs – such as the Health Pooled Fund – which a HCW noted ensured timely provisions of incentives.41 However, some HCWs and health leaders have remarked delays ranging from three months to 13 months.42 As one HCW noted: “The incentive is supposed to be paid monthly but currently there is a delay, it has been three months since they received the last incentive.� 43 These delays erode morale and contribute to higher attrition rates among rural Health worker. 44 HEALTH WORKERS RECRUITMENT, PERFORMANCE, AND RETENTION 33 Lutwama et al., “Health Services Supervision in a Protracted Crisis: A Qualitative Study into Supportive Supervision Practices in South Sudan.� 34 Lutwama et al. 35 KII with Rural HCW, Kapoeta South, Int. 2. 36 Lutwama et al. 37 KII with Health Leader, Juba, Int. 1; KII with Health Leader, Juba, Int. 4; KII with Health Leader, Juba, Int. 8. 38 KII with Rural HCW, Kapoeta South, Int. 1 and KII with Rural HCW, Renk County, Int. 4. 39 KII with Rural HCW, Kapoeta South, Int. 1; KII with Rural HCW, Kapoeta South, Int. 2; KII with Rural HCW, Geiger Payam, Int. 3; KII with Rural HCW, Renk County, Int. 4; KII with Rural HCW, Torit County, Int. 5. 40 KII with Rural HCW, Kapoeta South, Int. 1; KII with Rural HCW, Kapoeta South, Int. 2 41 KII with Rural HCW, Kapoeta South, Int. 1. 42 KII with Rural HCW, Kapoeta South, Int. 1; KII with Rural HCW, Geiger Payam, Int. 3; KII with Rural HCW, Torit County, Int. 5; KII with Health Leader, Juba, Int. 8. 43 KII with Rural HCW, Geiger Payam, Int. 3. 44 KII with Rural HCW, Kapoeta South, Int. 1. 11 Health workforce gaps in South Sudan are both vast and systemic, reflecting a shortfall of over 26,000 health workers required to meet core service delivery benchmarks.45 With only around 8,700 health workers currently deployed, the sector faces a severe staffing crisis, particularly in achieving high birth attendance and broader service coverage goals. Projections from the World Bank indicate that nearly twice that number would be needed to implement a fully comprehensive primary care package nationwide.46 These gaps are not simply numerical but reflect deeper structural limitations in the country’s human capital ecosystem, which is marked by extremely low tertiary enrolment rates, widespread illiteracy, and misalignment between educational outputs and health sector demands.47 Barriers to training access remain a critical chokepoint in the health worker pipeline. Less than one percent of youth are enrolled in tertiary education, and only 17 percent completed secondary school, with major gender and geographical disparities compounding the issue.48 Many aspiring health professionals are unable to meet curriculum standards, particularly in science subjects, due to weak foundational education, especially for girls.49 Even when willing, prospective trainees are hindered by the financial burden of tuition, distant or inaccessible training centers, and sociocultural norms that limit women’s participation in formal education.50 Further, the proliferation of poorly regulated private training institutes reportedly risks compromising educational quality, with little standardized oversight, curriculum alignment, or qualified instructors.51 These weaknesses are amplified in rural areas where facilities often receive the same incentive rates as their urban counterparts, despite facing greater logistical and security challenges.52 The rural-urban divide continues to distort recruitment and service delivery patterns. Training institutions are primarily concentrated in urban areas, reducing access for rural youth who might be more inclined to serve their communities if properly trained and supported.53 Opportunities to "grow your own"54 workforce - through rural-based training programs and community-integrated mentorship - remain largely untapped despite their reported impact on long-term retention. Recruiting students from underserved areas, offering scholarships, and tailoring curricula to reflect local needs could help reverse the current urban bias in workforce production.55 The recruitment process is further undermined by inconsistent standards, informal practices, and lack of regulatory oversight. While community-based selection of community health workers is common, formal criteria such as minimum education or local language proficiency are inconsistently applied or overlooked. This is particularly the case in rural areas where literacy rates are low and community 45 World Bank, South Sudan Human Capital Review (Washington, DC: World Bank, 2025), 59. 46 World Bank, South Sudan Human Capital Review, 59. 47 World Bank, South Sudan Human Capital Review, 63. 48 World Bank, South Sudan Human Capital Review, 63. 49 KII with Health Worker, Juba 50 Sheila Carrette and Isha Nirola, “Health Training Institute Assessment: Tackling the Skilled Health Worker Shortage in South Sudan� (World Bank, 2025). 51 KII with Health Worker, Juba 52 Carrette and Nirola, “Health Training Institute Assessment.� 53 G.W. Lutwama Lutwama and E. Jacobs, “Community Health Interventions in South Sudan� (The Netherlands: KI T Royal Tropical Institute, 2024); Carrette and Nirola, “Health Training Institute Assessment.� 54 Belinda Gabrielle O’Sullivan et al., “Editorial: Effective Strategies to Develop Rural Health Workfo rce in Low and Middle- Income Countries (LMICs),� Frontiers in Public Health 9 (2021). 55 Sunny C Okoroafor et al., “An Overview of Health Workforce Education and Accreditation in Africa: Implications for Scalingup Capacity and Quality,� Human Resources for Health 20, no. 1 (2022): 37. 12 preferences might dominate the process.56 Although community-led selection enhances social legitimacy, researchers found instances where selection guidelines were not followed, and candidates lacking required education or training were deployed directly into communities without supervised practice.57 Moreover, women face a double disadvantage. While some communities prefer female CHWs, women's literacy rate is only 19.2%, making it harder for them to meet even basic eligibility standards.58 Differences were revealed in training modalities across counties, namely in terms of duration, quality, and training methodologies, reportedly due to the lack of standardized modules or funds in certain locations.59 Incentives for rural postings remain insufficient to retain staff where they are needed most. As discussed in previous sections, rural health workers cited irregular salaries, insufficient housing, limited educational opportunities for their children and insecurity as key deterrents to rural deployment.60 In some areas, referral systems are non-functional, and electricity and water are unavailable in clinics, making it difficult to deliver basic healthcare.61 Even mid-level cadres, such as clinical officers, are reluctant to remain in these areas unless conditions improve.62 Notably, language barriers were considered surmountable, but the lack of physical infrastructure and personal safety were major deterrents.63 Health worker retention is found to be linked to facility conditions and the availability of accommodation. Nearly all KII respondents from rural areas emphasized that working in dilapidated or poorly equipped clinics made them feel ineffective, especially when required to rely on “clinical sense�64 due to the absence of diagnostic tools. This sense of futility in under-resourced settings drives absenteeism and attrition, reducing performance and retention of personnel.65 Accommodation emerged as a key determinant of rural retention: one health worker explained, “health workers may prefer to work in cities where they can earn more money and rent a house to ensure privacy… Of these [factors], accommodation is the primary one�.66 This view was echoed across rural KIIs, indicating that basic infrastructure, particularly staff housing near facilities, is essential to retaining personnel.67 Poor performance is often rooted in structural barriers that also affect recruitment and retention. These include irregular pay, lack of essential supplies, high workloads due to staff shortages, and - as discussed in the previous section - non-functional supervisory systems.68 Many health workers highlighted the absence of pre-deployment mentorship, on-the-job supervision, or any mechanism for evaluating performance and providing feedback.69 Performance is further constrained when workers are placed in facilities that lack even the minimum tools needed to do their jobs safely and effectively.70 As such, 56 George William Lutwama, Maryse Kok, and Eelco Jacobs, “An Exploratory Study of the Barriers and Facilitators to the Implementation of Community Health Worker Programmes in Conflict-Affected South Sudan,� Conflict and Health 15, no. 1 (November 18, 2021). 57 Lutwama, Kok, and Jacobs, “Barriers and Facilitators.� 58 Lutwama, Kok, and Jacobs, “Barriers and Facilitators.�; KII with Health Worker 59 Lutwama, Kok, and Jacobs, “Barriers and Facilitators.� 60 Balbir Deswal, “Reaching the Unreached - Challenges and Experiences in South Sudan,� World Wide Journal of Multidisciplinary Research and Development 3 (December 2017): 292–96; KII with Health Workers, Renk county and Kapoeta South 61 KII with Health Worker, Kapoeta South, Int. 1 62 KII with Health Worker, Renk county, Int. 4 63 KII with Health Workers, Renk and Torit counties, Int. 2 & 5 64 KII with Health Worker, Renk county, Int. 4 65 Deswal, “Reaching the Unreached�; Lutwama and Jacobs, “Community Health Interventions� 66 KII with Health Worker, Kapoeta South, Int. 1 67 KII with Health Workers, Kapoeta South, Renk county and Torit county 68 Lutwama and Jacobs, “Community Health Interventions� 69 Lutwama, Kok, and Jacobs, “Barriers and Facilitators.� 70 KII with Health worker, Renk county, Int. 4 13 boosting health worker performance will require addressing these foundational constraints, not just providing clinical training. Career progression and working conditions are conducive to health worker performance and retention. Community health workers and mid-level cadres frequently operate in isolation, with limited opportunities for skills enhancement or peer support.71 Providing clear job descriptions and defining pathways for career progression - particularly for rural staff - can reinforce their sense of purpose and legitimacy. Rural Health Workers also cited regular refresher trainings, opportunities to upskill, and integration into national accreditation systems as motivators to stay in post.72 These measures are particularly urgent given that many health worker roles are reportedly filled based on tribal affiliation or informal connections rather than professional qualification.73 A coordinated and community-anchored strategy is needed to stabilize South Sudan’s health workforce. Locally trained staff, supported by scholarships, consistent salaries, and decent working conditions, are more likely to remain in post. Non-financial incentives - such as farmland allocation for subsidence, peer support, and recognition - can supplement material inputs to strengthen retention.74 Aligning recruitment, training, and deployment with community needs, and adopting a lifecycle perspective in workforce planning, will be critical to transforming the country’s health system into one that is both resilient and equitable.75 RECOMMENDATIONS Based on the findings, the following recommendations pertaining to 1) rural health worker recruitment and 2) rural health worker performance/retention are provided. HEALTH WORKER RECRUITMENT/DEPLOYMENT 1. Establish a “Rural Health Workforce Pathway� to expand equitable access to training and recruitment. The current health worker training and recruitment system in South Sudan is fragmented and disproportionately benefits urban populations, leaving rural areas critically underserved. Training institutions are concentrated in cities, limiting access for rural youth -particularly women - who face additional barriers such as financial constraints, distance, and social norms that discourage their participation. To address this imbalance, the MoH and partners should establish a dedicated Rural Health Workforce Pathway aimed at improving access to training and enhancing rural recruitment through context-sensitive, community-rooted strategies. • Short-term: Introduce targeted scholarships, fee waivers, and outreach campaigns to recruit rural and female students into existing training programs, removing financial and informational barriers to entry. These measures should be implemented in partnership with international donors, pooled funding mechanisms (e.g., Health Sector Transformation Project76), and non-governmental 71 Lutwama, Kok, and Jacobs, “Barriers and Facilitators.� 72 Lutwama, Kok, and Jacobs, “Barriers and Facilitators.�; KII with Health Worker, Renk county, Int. 4 73 Carrette and Nirola, “Health Training Institute Assessment.� 74 KII with Health Worker, Renk county, Int. 4; O’Sullivan et al., “Effective Strategies to Develop Rural Health Workforce.� 75 World Bank, South Sudan Human Capital Review, 63. 76 World Bank, “South Sudan - Health Sector Transformation Project,� World Bank, 2025. 14 organizations already active in health education, as targeted scholarships, fee waivers and outreach campaigns add recurring expenses that can be substantial over time. Collaborating with financing partners is therefore essential to ensure the sustainability of these initiatives. • Medium-term: Set up satellite training hubs co-located with rural primary health care facilities that offer modular, community-integrated pre-service training to reduce the burden of relocation and improve practical readiness. • Long-term: Institutionalize the pathway in national policy, including rural trainee quotas, harmonized curricula, and mechanisms for transitioning rural-trained candidates into national accreditation and deployment systems. 2. Institutionalize a national pre-deployment practicum and mentorship scheme for new Health Workers. A major weakness in South Sudan’s health workforce system is the absence of structured, supervised practical experience for newly trained health workers, especially those deployed to rural areas. Many community health workers are sent into service without having received hands-on experience or mentorship, leaving them unprepared to deliver quality care and more likely to leave their posts prematurely. This gap in pre-deployment preparation undermines both performance and retention, particularly in isolated and under-resourced settings. To build professional confidence and improve service delivery outcomes, a national mentorship practicum should be introduced as a core element of health worker onboarding. • Short-term: Revise Community Health Workers and mid-level training curricula to include mandatory supervised practicums in nearby health facilities, ensuring trainees gain real-world experience before deployment. • Medium-term: Identify and support experienced rural-based health workers to serve as designated mentors or preceptors, providing them with recognition and modest incentives to formalize peer-based learning. • Long-term: Establish a national mentorship and early-career support system linked to licensing and professional development, ensuring consistent technical guidance and accountability from the outset of a health worker’s career. It is important to note that several upfront costs need to be considered, such as investments in needs assessments and data collection for effective planning. While ongoing adjustments to deployment and recruitment process may require additional administrative resources, aligning these efforts more closely with community needs can yield long-term savings by improving retention and reducing the costs associated with frequent staff turnover. To maximize feasibility under current fiscal constraints, it is important to take the following into account: (i) leveraging existing community structures and local leaders for recruitment; (ii) utilizing digital data collection tools, like DHIS2, where infrastructure exists; and (iii) focusing on non-financial incentives such as recognition and peer support to help support workforce stability without significant financial investment. 3. Design inclusive training models to bridge the gap for low-literate and underqualified candidates. A significant share of South Sudan’s potential health workforce is excluded from training opportunities due to low literacy levels and incomplete formal education - particularly among women and rural populations. Despite strong community ties and willingness to serve, these individuals often cannot meet formal entry requirements and are left out of workforce development efforts. This represents a missed opportunity to build a more community-rooted health workforce and improve equity in service delivery. 15 To bridge this gap, the MoH and partners should develop adaptive training models that combine foundational skills development with competency-based health training. These adaptations can build off the current system, making them a lower cost option. • Short-term: Pilot preparatory bridging courses in selected counties, combining basic literacy and numeracy with visual and oral health education tailored for low-literate candidates. This approach draws on successful models such as Ethiopia’s Health Extension Program (HEP), which integrated foundational education into pre-service health training to enable rural women with limited formal education to become effective community health workers.77 • Medium-term: Integrate inclusive learning approaches - such as pictogram-based modules, scenario-based training, and supervised hands-on practice - into national CHW and auxiliary curricula. This can be piloted through the current Health Sector Transformation Project (HSTP), co- led by the World Bank, the Ministry of Health, and other partners—particularly its focus on the Boma Health Initiative and the Bome Health Worker (BHW) cadre in South Sudan • Long-term: Create an accredited, progressive training track that allows youth with limited formal education to qualify for health roles through phased certification, supervised practice, and structured skills development. Accreditation should be led by the Ministry of Health in partnership with regional professional councils, such as the East, Central and Southern Africa College of Nursing (ECSACON), alongside global technical agencies like WHO and UNFPA, which have existing mandates and experience in competency-based health training and certification in fragile and post-conflict settings. HEALTH WORKER PERFOMANCE/RETENTION 1. Implement and expand reforms pertaining to both financial and non-financial incentives to address rural health worker demands. The current incentives model for rural health workers is insufficient for long-term retention, as the cash-based disbursements have not been consistently adhered to. As some rural health workers have not received their salary in at least a few months, some have started to openly call for these reforms to ensure a stable health workforce.78 Despite these workers still committing to serving their constituent communities, these delays have strained their willingness to continue serving and leading to further attrition towards better opportunities in urban centers. To assuage these concerns from rural health workers, the MoH and implementing partners should prioritize redressing the current backpay for active health workers and developing a new incentives package model. • Short-term: Assess the backlog of delayed incentive disbursements given the roster of active rural health workers supported under the South Sudan Health Sector Transformation Project (HSTP) and other peer programs per county. Regional subgrantees (i.e., civil society organizations (CSO) engaged by UNICEF) would need to report the date(s) of most recent disbursement and the number of staff enlisted to swiftly account the pending balance that would need to be fulfilled. This will require immediate allocation of funds to cover outstanding payment. This could strain 77 Abraham Haileamlak and Israel Ataro, “The Ethiopian Health Extension Program (HEP) Is Still Relevant after 15 Years of Implementation Although Major Transformation Is Essential to Sustain Its Gains and Relevance,� Ethiopian Journal of Health Sciences 33, no. 1 (2023). 78 Yang Ater, “Lakes State Health Workers Call for Timely Pay,� Eye Radio, June 3, 2025, https://www.eyeradio.org/lakes -state- health-workers-call-for-timely-pay/. 16 the budget in the short term but potentially improve retention and thus reduce long-term costs associated with recruitment and training. • Medium-term: Expand financial incentive distribution pathways to include direct bank transfers and mobile money transfers. This would include CSOs leveraging different mobile money platforms (i.e., m-Gurush, Nilepay) to allow rural health workers with basic mobile access to receive their incentive/salary. This would require investment in infrastructure and partnerships with mobile money platforms. However, this could reduce administrative costs and improve transparency in the long run. • Long-term: Organize a stakeholder plenary session including rural health worker representatives and CSOs from differing counties to discuss potential options for developing a new incentives package. A stakeholder plenary is a relatively low-cost activity that can help ensure new incentive packages are aligned with the needs and priorities of health workers. Moderations should be led by the Ministry of Health with support from UNICEF, as well as addressing financial considerations for the non-financial incentives (i.e., expanded staff boarding, satellite-linked telecommunication in rural areas, transportation stipends). This will require careful planning and stakeholder consultation to design cost-effective package. Non-financial incentives may have lower upfront costs but require ongoing maintenance and support. 2. Develop a comprehensive plan for rural health facility infrastructure rehabilitation and expansion. The current state of rural health infrastructure and inventory capacity heavily limits the health workers’ ability to adequately serve their communities. Additional inventory stockouts experiences also hamper the quality of care, leading to community members questioning the ability of rural health workers to provide these services, further declining their performance and willingness to stay in their post. As these more systemic limitations are undermining health worker confidence in their capacity to serve, the Ministry of Health and partners need to determine a plan of action for rehabilitating these rural health facilities, which in turn improves the health worker capacity to provide health services. • Short-term: Conduct a comprehensive review of rural health facility infrastructure to verify deficiencies in facility accommodations and service availability reported by rural health workers. County officials and CSOs would develop an evenly distributed sample of facilities across different counties to determine the extent of these gaps in services and accommodations. • Medium-term: Increase the supply replenishment intervals for rural health facilities ranging from county hospitals to rural outposts from a quarterly basis to a bimonthly basis, with estimated supply requirements accounting for unpredictable influxes of service users. This would also rely on supply partners (i.e., WHO, Gavi) to adjust their storage capacity at regional warehouses and delivery transportation schedule to fulfill a more frequent replenishment of essential inventory. • Long-term: Develop a plan of public-private partnerships to invest in the following: 1) on-site electrification via generators or renewable energy, 2) increased ambulance capacity, and 3) facility structural expansion and maintenance, including security fencing. The Ministry of Health, under the technical support of UNICEF, would issue requests for proposals by local firms to implement the structural improvements, with local oversight conducted by county-level administration and CSOs. 17 ANNEX Figure 1. PRISMA Diagram for the Systematic Review (via Covidence) 18