Article by Dr. Yohanis Riek, a Resident in Surgery and health sector analyst. He writes about healthcare governance, humanitarian, and health systems strengthening.
What South Sudan’s HSTP cuts reveal about power, priorities, and whose health counts
A few days ago, a letter was written in Juba.
It did not mention a single patient by name.
It did not describe a woman in obstructed labour, a child with severe malaria, or a family fleeing floodwaters with nowhere to go.
But that letter will decide whether those people receive care.
On 24 January 2026, South Sudan’s Ministry of Health announced that 102 health facilities would lose support under the Health Sector Transformation Project (HSTP). The explanation was simple — and familiar: the money was not enough.
This is not only a story about mismanagement.
It is not a story about a single donor decision.
It is a story about what happens when budgets begin making moral choices — about who remains reachable, who becomes dispensable, and who must travel farther, wait longer, or simply go without care.
In fragile countries like South Sudan, where conflict and climate shocks are not exceptions but the operating environment, such decisions are never neutral. They redraw the map of access. They redistribute risk. And they quietly determine who absorbs the cost of “sustainability.”
This article examines the 24 January letter not as a routine implementation update, but as a de facto health policy decision. It analyses the logic behind the cuts, the criteria used to select facilities, the consultation process that preceded them, and their alignment with South Sudan’s own policy commitments — namely the Health Sector Strategic Plan (2023–2027), the revised Basic Package of Health and Nutrition Services (2019), the HSTP Stakeholder Engagement Plan (2023), and the World Bank–financed HSTP Project Appraisal Document (2023).
Drawing on health systems resilience theory and humanitarian health principles, the article argues that the decision prioritises fiscal containment over population health need, underutilises adaptive service delivery models such as mobile and outreach care, and departs from the participatory governance commitments embedded in national policy and project design.
It concludes by proposing an alternative, adaptive framework — one that treats insecurity and climate shocks not as reasons to withdraw care, but as reasons to redesign how care is delivered.
A Financial Memo With Population-Level Consequences
In fragile and conflict-affected settings, health system decisions are rarely neutral. They redistribute risk, redefine access, and determine who bears the consequences of fiscal stress.
On 24 January 2026, South Sudan’s Ministry of Health (MoH) issued a letter titled Updates on the Implementation of the Health Sector Transformation Project (HSTP), addressed to the Governors of the ten States and the Chief Administrators of the three Administrative Areas.
The letter announced a set of “adjustments” to HSTP implementation, most notably the discontinuation of project support to over 100 health facilities across the country.
Although the letter presents itself as an operational update intended to preserve project viability through June 2027, its implications extend far beyond project management.
By withdrawing support from primary and secondary health facilities, reducing hospital support levels, and scaling down health worker incentives and training, the decision reshapes the effective health service coverage available to millions of people — many of whom live in areas affected by conflict, flooding, displacement, and chronic poverty.
This was not just a budgeting decision — it was a service geography decision.
I argue that the letter constitutes a de facto health policy decision, rather than a mere administrative adjustment. As such, it warrants scrutiny against South Sudan’s own health policy framework and the explicit commitments of the HSTP project itself.
Where HSTP Sits in South Sudan’s Health System — and Why That Matters
The Health Sector Transformation Project (HSTP) is the flagship investment underpinning South Sudan’s health sector reform agenda. Financed primarily through the World Bank and implemented through a combination of government stewardship, UN agencies, and non-governmental partners, HSTP aims to expand access to the Basic Package of Health and Nutrition Services (BPHNS), strengthen health system governance, and improve resilience in a context characterised by protracted crisis.
The project is explicitly aligned with the Health Sector Strategic Plan (HSSP) 2023–2027, which articulates health as a human right and commits the Government of South Sudan to equitable access to essential services, with particular attention to vulnerable and crisis-affected populations (MoH, 2023a). The HSSP recognises the structural fragility of the health system and explicitly includes emergency and humanitarian modalities — such as mobile medical teams — as integral components of national service delivery.
Similarly, the Basic Package of Health and Nutrition Services (BPHNS) defines a tiered service model in which PHCUs and PHCCs form the backbone of preventive, promotive, and basic curative care, supported by referral to county, state, and tertiary hospitals (MoH, 2019).
The BPHNS explicitly incorporates outreach and mobile service delivery as mechanisms for reaching hard-to-access populations.
The HSTP Stakeholder Engagement Plan (SEP) further commits the project to inclusive, transparent, and continuous engagement with a wide range of stakeholders, including community representatives, traditional leaders, women’s and youth groups, and vulnerable populations (MoH & UNICEF, 2023).
Against this backdrop, any decision to withdraw services must be evaluated not only in terms of fiscal prudence, but also in relation to these strategic commitments.
What the 24 January 2026 Letter Actually Does to the Health System
The MoH letter announces a package of measures justified as necessary to ensure the financial sustainability of HSTP. These include:
- Discontinuation of HSTP support to 102 health facilities nationwide.
- Reduction of support to six hospitals, downgrading them to lower service levels.
- Progressive reduction of health worker incentives.
- Reductions in facility operational costs.
- Scaling down of in-service training.
Taken together, these measures represent a contraction of the publicly financed service footprint, particularly at the primary care level. Analysis of the annexed facility list shows that the majority of discontinued facilities are PHCUs and PHCCs, the very entry points intended to ensure proximity, early care-seeking, and preventive services.
Primary care is not where systems can afford to retreat.
The annex data reveals that service discontinuation is not evenly distributed across the country.
The type of facilities discontinued matters as much as their number.
While the letter frames these changes as a “last resort,” it does not provide a detailed transition plan for affected communities, nor does it articulate how service gaps will be mitigated through alternative delivery models.
The Decision Logic: When Fiscal Sustainability Becomes the Dominant Lens
The letter’s justification follows a linear logic:
- HSTP faces financial sustainability challenges.
- Cost-containment measures across implementing partners were insufficient.
- Service discontinuation is therefore required to preserve the project and avoid abrupt disruption.
This framing reflects a project-centric view of sustainability, focused on keeping expenditures within available financing envelopes. While fiscal realism is necessary, the absence of a parallel population health impact assessment is striking.
Health policy analysis literature consistently emphasises that in low-income and fragile settings, efficiency-driven retrenchment without equity safeguards risks exacerbating existing disparities (Kruk et al., 2018). In South Sudan, where public provision is already the primary — or only — source of care for many communities, withdrawal of services can translate directly into increased morbidity and mortality.
How Facilities Were Selected: Stated Criteria and Hidden Assumptions
The MoH letter identifies several criteria used to select facilities for discontinuation:
- Security and operating environment.
- Operational status, particularly facilities closed for extended periods.
- Facility functionality.
- Overlap with nearby facilities.
- The need to preserve major facilities and referral pathways.
While these criteria are not inherently unreasonable, the letter does not disclose how they were operationalised. Critical questions remain unanswered.
What the Letter Does Not Explain:
- How “extended closure” was defined
- How functionality was measured
- What distance or access thresholds defined “overlap”
- Whether displacement patterns, seasonal flooding, or insecurity corridors were considered
- Whether epidemiological need or service utilisation data informed decisions.
The absence of methodological transparency undermines the accountability of the decision and makes it difficult for subnational authorities and communities to assess its fairness or accuracy.
The Missing Equity Lens: Conflict, Displacement, and Climate Shocks
In fragile systems, security should trigger adaptation, not withdrawal.
One of the most troubling aspects of the decision is its treatment of insecurity and environmental shocks as reasons for withdrawal rather than adaptation. Many of the discontinued facilities are located in areas affected by active conflict, recurrent flooding, or large-scale displacement — precisely the contexts where health needs are highest.
The HSSP (2023–2027) explicitly recognises this reality, committing to emergency response mechanisms including mobile medical teams and outreach services to ensure continuity of care in humanitarian settings (MoH, 2023a). The HSTP Project Appraisal Document similarly emphasises climate resilience and adaptive service delivery as core design features (World Bank, 2023).
By contrast, the letter treats insecurity as a filtering criterion for exclusion, not as a trigger for alternative delivery models. This represents a fundamental departure from the resilience-oriented approach articulated in national policy.
Adaptation Foregone: Why Mobile and Outreach Services Were Not Used
As Kruk et al. (2015) argue, resilient systems adapt to crises by absorbing shocks and continuing core functions, rather than rigidly maintaining existing structures. In fragile settings, this often requires shifting from fixed-facility models to mobile, outreach, and community-based approaches.
What Adaptation Could Have Looked Like
South Sudan’s policy framework explicitly allows for such adaptation. According to the BPHNS (2019), outreach and mobile service delivery are central strategies for reaching underserved and remote communities. The HSSP identifies mobile medical teams as essential in emergencies. The HSTP project design incorporates community and outreach platforms alongside clinical facilities.
Yet the 24 January letter does not reference any plan to redeploy resources toward mobile or outreach services in areas where fixed facilities are discontinued. This omission suggests a narrow interpretation of service delivery, constrained by facility-based accounting rather than population-based needs.
In a system designed for chronic instability, adaptation is not an optional innovation — it is the core operating logic.
Who Was Consulted — and Who Was Not
The HSTP Stakeholder Engagement Plan (SEP) issued in November 2023 identifies a broad range of stakeholders as critical to project success, including:
- Community representatives and gatekeepers.
- Traditional chiefs and cultural leaders.
- Women’s and youth groups.
- Local civil society organisations.
- Vulnerable and marginalised populations.
The SEP emphasises meaningful, culturally appropriate consultation and continuous engagement, particularly when project decisions affect access to services (MoH & UNICEF, 2023).
The MoH letter, however, references consultations primarily with State Ministers of Health, donors, UN agencies, and the executive branch. While these actors are important, the absence of any mention of community-level engagement represents a significant departure from the SEP’s commitments.
In contexts where trust in public institutions is fragile, excluding community voices from decisions that directly affect service access risks eroding legitimacy and compliance.
Who Pays for Sustainability? The Political Economy of HSTP Cuts
From a political economy perspective, the HSTP adjustment shifts the costs of fiscal constraint downward. While the project may achieve financial sustainability on paper, the real costs are borne by:
- Communities who lose nearby access to care.
- Health workers facing reduced incentives and training.
- State and county authorities tasked with managing the fallout without additional resources.
This pattern reflects a broader tendency in aid-dependent systems for sustainability to be achieved through service contraction rather than resource mobilisation, efficiency gains, or adaptive redesign.
While this analysis focuses on South Sudan, the dilemma it exposes is not unique. Across fragile and aid-dependent health systems, financial sustainability is increasingly pursued through service contraction rather than adaptive redesign — raising urgent questions about whose health is protected when resources tighten.
What an Adaptive Alternative Could Look Like
An alternative approach — more consistent with South Sudan’s policy framework — would include:
- Publishing the data and criteria used for facility selection.
- Applying an explicit equity and vulnerability weighting.
- Substituting closures with mobile, outreach, or community delivery.
- Engaging traditional leaders, women’s and youth groups as this directly affect them.
- Establishing grievance and correction mechanisms to allows for review and amendment of decisions based on new evidence.
- Treating sustainability as one objective — not the only overriding determinant.
Resilience is measured by who remains covered when conditions worsen.
Sustainability without equity is not transformation
The 24 January 2026 MoH letter marks a pivotal moment in South Sudan’s health transformation trajectory. While fiscal constraints are real, the manner in which they are addressed matters profoundly. When cost-containment becomes the primary driver of health policy, without sufficient attention to equity, adaptation, and participation, the result is not transformation but retrenchment.
True health system transformation in fragile settings requires decisions that prioritise human need, leverage adaptive delivery models, and honour commitments to inclusive governance. Anything less risks undermining the very objectives HSTP was designed to achieve.
The question is no longer whether health systems can afford to adapt.
The question is whether they can afford not to — when the cost of retrenchment is paid in delayed care, preventable deaths, and communities pushed further from the promise of universal health coverage.
This analysis is based on publicly available policy documents and the official Ministry of Health annex accompanying the 24 January 2026 HSTP implementation letter.
References
Ministry of Health, Republic of South Sudan. (2019). Revised Basic package of health and nutrition services for primary, secondary and tertiary health care in South Sudan. Juba: MoH.
Ministry of Health, Republic of South Sudan. (2023a). Health sector strategic plan 2023–2027. Juba: MoH.
Ministry of Health, Republic of South Sudan, & UNICEF. (2023). Health Sector Transformation Project stakeholder engagement plan. Juba: MoH.
Ministry of Health, Republic of South Sudan. (2026). Updates on the implementation of the Health Sector Transformation Project (HSTP) (Letter to Governors and Chief Administrators, 24 January 2026). Juba: MoH.
World Bank. (2023). South Sudan health sector transformation project (HSTP): Project appraisal document (Report No. P181385). Washington, DC: World Bank.
Kruk, M. E., Myers, M., Varpilah, S. T., & Dahn, B. T. (2015). What is a resilient health system? Lessons from Ebola. The Lancet, 385(9980), 1910–1912. https://doi.org/10.1016/S0140-6736(15)60755-3
Kruk, M. E., Gage, A. D., Arsenault, C., Jordan, K., Leslie, H. H., Roder-DeWan, S., … Pate, M. (2018). High-quality health systems in the Sustainable Development Goals era: Time for a revolution. The Lancet Global Health, 6(11), e1196–e1252. https://doi.org/10.1016/S2214-109X(18)30386-3