Five-year Health Sector Strategy: Investing in Health and Achieving the MDGs 2007-2011

بسم اهللا الرحمن الرحيم Republic of Sudan Federal Ministry of health 5-year Health Sector Strategy: Investing in Health and Achieving the MDGs 2007-2011 1 Table of contents: Acronyms and abbreviations ......................................................................................................................... 2 1 Introduction ........................................................................................................................................... 3 1.1 Why a 5 years strategy: ............................................................................................................... 3 1.2 The strategy development Process: ............................................................................................ 3 1.3 Policy context ............................................................................................................................... 4 1.4 General Guiding Principles for the Health strategy ...................................................................... 4 2 Situation Analysis .................................................................................................................................. 6 2.1 Demography and Geography: ...................................................................................................... 6 2.2 Socio- Cultural context ................................................................................................................. 6 2.3 Economic context ......................................................................................................................... 6 2.4 Political context ............................................................................................................................ 8 2.5 Epidemiologic context .................................................................................................................. 9 2.6 Health system: ............................................................................................................................. 9 2.6.1 Governance ......................................................................................................................... 9 2.6.2 Service delivery and system resources: ............................................................................ 11 2.6.3 Planning and management of human resources for health (HRH) ................................... 15 2.6.4 Financing of Health Services: ............................................................................................ 18 2.7 MDGs ......................................................................................................................................... 19 2.7.1 A- MDGs current status and trends ................................................................................... 19 2.8 Goal 4: Reduce child mortality ................................................................................................... 20 2.9 Goal 5: Improve maternal health: ............................................................................................... 25 2.10 Goal 6: HIV/AIDS, malaria and other diseases .......................................................................... 27 2.10.1 HIV/AIDS control and prevention ...................................................................................... 27 2.10.2 Malaria control – status and trends ................................................................................... 30 2.10.3 TB control – status and trends .......................................................................................... 32 2.10.4 Schistosomiasis & STH control – status and trends ......................................................... 33 2.10.5 Leishmaniasis: ................................................................................................................... 33 2.10.6 Lymphatic Filariasis ........................................................................................................... 34 2.10.7 Sleeping Sickness ............................................................................................................. 34 2.10.8 Guinea Worm (Dracunculosis): ......................................................................................... 34 2.10.9 onchocerciasis ................................................................................................................... 35 2.10.10 Leprosy: ........................................................................................................................ 35 2.11 Prevention and Control of Outbreaks ......................................................................................... 36 3 Challenges and opportunities ............................................................................................................. 38 3.1 CHALLENGES ........................................................................................................................... 38 3.2 OPPORTUNITIES ...................................................................................................................... 39 4 Guiding polices and long term strategies: .......................................................................................... 41 4.1 The 25 year Strategy .................................................................................................................. 41 4.2 The National Health Policy, 2006 ............................................................................................... 41 4.3 Health Policy South Sudan (1998) ............................................................................................. 41 4.4 Joint Assessment Mission Framework 2006-11 (JAM) .............................................................. 41 5 Strategic framework: ........................................................................................................................... 44 6 VISION FOR HEALTH ........................................................................................................................ 46 7 MISSION STATEMENT ...................................................................................................................... 46 8 Goals, Strategic Objectives, Targets and Indicators .......................................................................... 46 9 Strategies and key interventions ......................................................................................................... 55 10 Priority strategic interventions ........................................................................................................ 55 11 Key activities: .................................................................................................................................. 71 12 Implementation, Monitoring and Evaluation framework: ................................................................ 92 13 References ................................................................................................................................... 101 14 Acknowledgements: ..................................................................................................................... 101 15 Annexes ........................................................................................................................................ 101 2 Acronyms and abbreviations AIDS Acquired Immunodeficiency Syndrome ACT Artemisine combination therapy ANC Ante Natal Care CBOs Community based organization BHUs Basic Healthy Units CBIs Community based initiative CBS Central Bureau of Statistics CHWs community health workers CFR Case Fatality Rate CMH Commission on Macroeconomics and Health CMR Child Morality Rate CPA Comprehensive Peace Agreement CVD Cardio-vascular disease DHS Demographic and Health Survey D-JAM Darfur Joint Assessment Mission DS Dressing stations EmOC Emergency Obstetrics Care GAVI Alliance Global Alliance for Vaccines and Immunization GGE The general government budget GFTAM Global fund to fight TB, HIV/AIDS and Malaria GoNU Government of National Unity GoSS Government of South Sudan HMN Health Metrics Network HRH Human Resources for Health IMCI Integrated management of childhood illnesses IMR Infant Mortality Rate ITNs Impregnated bed-nets JAM The Joint Assessment Mission LHA Locality Health Administration LLINs Long lasting impregnated bed-nets M&E Monitoring and Evaluation MDGs Millennium Development Goals MICS Multiple Indicators Cluster Survey MMR Maternal Mortality Ratio MOH Ministry of Health NCD Non communicable diseases NGOs Non-Governmental Organizations NMR Neonatal Mortality Rate PHC Primary Health Care (PHCU) Primary Health Care Unit SHHS Sudan Household Survey SMOH Sate Ministry of Health SMS Safe motherhood Survey PMTCT Prevention of mother to child transmission TBAs Traditional Birth Attendants TFR Total Fertility Rate VCT Voluntary counseling and testing 3 1 Introduction 1.1 Why a 5 years strategy: The health sector has prepared this 5 year strategy in response to the Government of National Unity (GoNU) initiative for developing a 5 year strategic plan for all sectors in Sudan. The purpose of this policy document is to provide a framework for the health system reform and sustainable development. It stipulates as well the most important health priorities to be addressed during the coming five years (2007-2011). The accumulated knowledge and better understanding of the health system during the past few decades necessitate structural changes in the health system. These structural changes are needed to allow for best practices to be applied and to respond to the dynamic political, cultural, socioeconomic, epidemiological and technological changes. This would require a comprehensive and thorough situational analysis and systematic approach for health system development. Further, health sector development should be underpinned by setting key strategic and policy directions based on the principles of accountability, transparency, participation and equity. Based on this strategic framework each department and programme will have to develop or update its detailed five year strategy. This strategy is focusing on investing on health of the people and fostering progress towards achieving the international commitment towards the Millennium Development Goals (MDGs). The strategy advocates for increasing government spending on health to a level that will enable the health sector to deliver quality acceptable and accessible preventive, promotive, curative and rehabilitative health services emphasizing the needs of the poor, the most vulnerable, and disadvantaged groups. The strategy is also advocating for removing barriers to access health services through pro poor policies, fostering equity and considering health as a basic human right. 1.2 The strategy development Process: The FMOH emphasized the importance of both the content of the document as well as the process. The initial draft of this document was prepared by the General Directorate of Health Planning and Development in consultation with MOH programme directors. This was preceded by the micro planning process (2005-2006) during which five year plans were developed for most of the localities. Using the information in the micro planning, the surveys and studies of the health system and policy issues, the routine health information and all available data from other sources the situation analysis was prepared. The Sudan Household Health Survey 2006 contributed by adding and updating many of the important indicators. A national team was formed to coordinate the process (see annex 1). The document benefited very much from the Assessment Mission Report of the Health System Division (EMRO-WHO) and the MDGs country report. It was developed in accordance with guidelines of the National Council for Strategic Planning. A UNICEF consultant was recruited to give technical assistance and advice on how to proceed with the process. The consultant reviewed the document and conducted individual and group meetings with MOH relevant staff and his input was incorporated. A number of groups by themes were formed to finalize the goals and interventions. These groups included Federal Ministry of Health (FMOH) department's directors and programme managers and UN technical staff from WHO, UNICEF and UNDP. The document is made available to ministers of health and general directors of State Ministries of Health (SMOH). Further wide consultation is intended to be carried out for more involvement of stakeholders. The strategy will be presented to the MOH Advisory Council. A meeting is planned with the ministers of health and general directors of State Ministries of Health (SMOH) to discuss the document 4 and add their inputs. Other meetings for the same purpose are planned for stakeholders in UN agencies, NGOs, workers in the health sector, related sectors and the community. For wide public input the document will be made available for public, health professionals and organizations through different methods. The strategy will then be submitted to the National Council for Strategic Planning for further discussions and approval. The strategy will be presented in a special conference to which all stakeholders will be invited. Necessary implementation arrangements and needed capacities will be put on place including the state and local levels, which will be overseen by sectoral oversight committees that involves all stakeholders both at the state and national levels. Effective and efficient monitoring and evaluation systems and mechanisms will be established to ensure that the implementation is on take and results are achieved. An annual, mid term and end term reviews based on the set forth performance indicators will be carried out to assess the progress toward achieving the goals and targets. 1.3 Policy context The policy context is shaped by the provision of the Interim Constitution of the Sudan (2005), the legal frameworks and jurisdictions and governmental laws and decrees in the country. The strategy is inspired by the regional and international initiatives and movements for which the Sudan is committed such as Abuja Declaration, the Millennium Development Declaration, the Alma Ata Declaration and Health for All and PHC approach and its recent development. The strategy is also guided by the national movement towards equity, poverty eradication, investing in health, achieving the MDGs, maintaining and securing human rights and dignity, preserving the rights of children and women and fighting disease and ignorance. This is in follow with the global strategies such as Health Promotion, Rollback Malaria (RBM), Stop-TB and Control of HIV/AIDS. The strategy is guided by a variety of existing health policies such as the National Health Policy, the 25-Year Strategy, Reproductive Health policy, Child Health Policy, HIV/AIDS Policy, Essential PHC Package Policy, the 10-Year Human Resources Strategy and other specific human resources documents such as the Sudan Declaration and Human Resources Management Policy. 1.4 General Guiding Principles for the Health strategy The following are the guiding principles as stipulated in the National health policy: • The National health system has to be founded on solid policies, based on best avaialable evidence. • Strategic plans with clear priorities, objectives, aims, performance-based targets (indicators) and outcomes are to be set out. • Primary health care will be considered as the approach for providing sustainable quality health care for all. • Health will be centeral to the overall development policy • Sustainable and equitable health care, especially for the poor, must be provided with special consideration to financial, technical and administrative sustainability. • Priority will be given to capacity building of the federal, state and locality levels in policy formulation, priority-setting, management and planning, as well as development of health information and research capacities. The role of community health workers within a functioning Local Area Health System to increase access to services at the community level and increase demand for service should be emphasized. The remuneration of this level of health workers will be given consideration. • Health will be used to enhance lasting peace and reconsilataion. 5 • Support will be given in ways that facilitate return to normal situation and lasting development. • Emphasis will be given to reforming health care financing to become pro-poor and to increase allocations for health. • The health system is to be built on principles such as adopting the comprehensive concept of health, attention to health promotion, continuous quality improvement and client satisfaction, accountability, equity, accessibility, affordability, appropriateness, efficiency, effectiveness, transparency, intersectoral collaboration, partnership, community participation, innovation, work values and ethics, gender equity and teamwork. These key strategic approaches will be enhanced in this next 5 years. • Strategies to scale up existing high impact, low cost interventions and introduce new interventions embodied in the Accelerated Child Survival Initiative as well as other health related MDGs should be pursued by the government and partners 6 2 Situation Analysis 2.1 Demography and Geography: With an area of one million square miles Sudan is the largest country in Africa. The Northern part of the country is an extension of Sahara desert, the central part is a dry Savannah area and the southern part is a tropical forest climate. The country has a total population of about 35.4 million [2005 estimates]. Out of this, 44% are below 15 years of age (55% in the south and 43.4% in the north) and 16.4% are below five years of age (24% in the south and 14.8% in the north). Life expectancy at birth is estimated around 55 years. Annual population growth is 2.6% and the total fertility rate is 5.9.1 Rural population constitutes about 68% of the total population; however there is an ongoing process of urbanization2. The population of metropolitan Khartoum is growing rapidly, exceeding 6 million, including internally displaced people (IDPs) from the southern war affected zone as well as western and eastern war/drought-affected areas. However, the majority of the displaced people have migrated seeking better job / educational opportunities3. 2.2 Socio- Cultural context Sudan is a multiethnic multicultural country with hundreds of ethnic and tribal divisions and languages. The northern states cover most of Sudan and include most of the urban centers. The majority of the 29.5 million Sudanese who live in this region are Arabic-speaking Muslims, though a large proportion of the population also speaks traditional non-Arabic mother tongue. The southern part has a population of around 6 millions with a predominantly rural, subsistence economy. This region has been severely affected by war since Sudan independence in 1956, resulting in lack of infrastructure development, major destruction and displacement. In this part of the country, people adhere mainly to indigenous traditional beliefs, although Muslims and Christians constitute a significant proportion. The Southern Sudan also has a number of tribal groups and many more languages. 2.3 Economic context In contrast to the challenges faced by many post-conflict countries, the macro-economic indicators are good, except for Sudan’s large external debt. The GDP per capita had shown significant increase during the last five years (due mainly to increased oil revenues and the flow of foreign investments) from US$ 395 in 2001 to US$ 640 in 2005 and above US$ 700 in 2006.4 The direct share of oil in GDP was only 6.8% in 2000 and increased to 16% in 2005, while agriculture contribution to the GDP has decreased from 46.3 % in 2000 to 39% in 2005. Further more, agriculture remains the main source of income for two out of three people in the north living in rural areas, and for more than 85% of those in the South.5 The general government expenditure (GGE) has increased from 352,160 million SD (US$ 1,371 million) in 2000 to 1,385,134 million SD (5,631 million US$) in 2005 and estimated to reach 2,130,000 million SD (9,467 million US$) in 2006. Fifty percent of the government budget in 2005 was from oil revenue. 1 CBS, UNFPA Population Data Sheet 2005, SMS 1999 2 Sudan, National population census (1993) 3 Taha, 1996, migration to Khartoum State 4 IMF, December 2005. Per capita estimates are for the entire country 5 Performance of the Sudan economy 200-2005, Ministry of Finance and National economy, April 2006, page 2 7 Rapidly growing Federal Government revenues hold the prospect for reversing the deterioration of the health care system. Federal Government transfers to the Northern States for example in 2005 were about US$ 28 per capita, or ten times the amount in 2000, and the 2006 budget allocates transfers equivalent to US$ 41 per capita. At the same time, the Government has adopted a medium-term expenditure framework (MTEF) which envisions raising domestic public expenditures on the health sector to 1.5% of GDP by 2008. A crucial policy challenge is to ensure that a significant proportion of increased transfers to states, and indeed of growing government health spending, is effectively channeled towards essential health services and to reducing the financial burden on households and social inequalities in access, utilization and health outcomes. The Joint Assessment Mission (JAM, 2005) estimated that additional resources of approximately US$ 200 million would be required annually in the following two years. This is to be increased to US$ 350 million in the subsequent 4 years in order to achieve significant progress towards the MDGs over all of Northern Sudan and the three areas. The estimation for the Southern Sudan is US$ 125 millions in the first two years to be increased to US$ 170 millions in the following 4 years. Table 1: contribution of the different sectors to the GDP (%)6 Year 2000 2001 2002 2003 2004 2005 sector Agriculture 46.3 45.6 46 44 40 39 Manufacturing 21.5 22.8 23.2 24.1 28 28 Oil 6.8 7.9 8.2 8.9 15 16 Others 14.7 14.9 15 15.2 13 12 Service 32.2 31.6 30.9 30.3 32 32 Public sector 5.8 6 5.9 5.7 11 13 private sector 26.4 25.6 25 24.6 21 19 6 Ibid, page 107 FMOH Health Expenditure Index (index year 2000) 0 100 200 300 400 500 600 700 800 2000 2001 2002 2003 2004 2005 2006 Years index MOHB index GOV.B 8 Table 2: Government expenditure on different line items as % of GDP7 2000 2001 2002 2003 2004 2005 Salaries (chapter 1) 3.5 3.8 4.2 4 5.2 4.9 Current cost (Chapter 2) 5.2 5.4 4.6 7 8.3 6.2 Capital investment (Chapter 3) 1 0.7 0.8 1 1.6 6.7 Development (Chapter 4 ) 1.7 2.2 3.6 4 5.8 4.9 Overall government expenditure 11.4 12.1 13.2 16 20.9 22.7 Table 3: contribution of different source of revenues to the GDP and Budget (%) 2000 2001 2002 2003 2004 2005 A. Tax revenues 5.2 5.46 5.48 5.78 7.97 8.2 1. customs 2.3 2.12 2.06 2.5 3.01 3.6 2. vat 0.5 1.09 1.06 1.22 1.39 1.4 3. others 1.2 1.07 1.31 0.91 2.16 1.6 4. direct tax 1.2 1.18 1.05 1.15 1.41 1.6 B. Non tax revenues 5.6 5.13 6.62 9.94 11.53 11.7 1. Oil 4.6 4.33 5.11 8.76 9.53 9.9 2. Others 1 0.8 1.51 1.18 2 1.8 Overall gover. revenues (A+B) 10.8 10.59 12.1 15.72 19.5 19.9 Table 4: contribution of different source to the government resource envelop (%) 2000 2001 2002 2003 2004 2005 % of revenues % of revenues % of revenues % of revenues % of revenues % of revenues Tax 48.15 51.56 45.29 36.77 40.87 41.21 1. Customs 21.30 20.02 17.02 15.90 15.44 18.09 2. VAT 4.63 10.29 8.76 7.76 7.13 7.04 3. Others indirect tax 11.11 10.10 10.83 5.79 11.08 8.04 4. Direct tax 11.11 11.14 8.68 7.32 7.23 8.04 Non tax 51.85 48.44 54.71 63.23 59.13 58.79 1. Oil 42.59 40.89 42.23 55.73 48.87 49.75 2. Other 9.26 7.55 12.48 7.51 10.26 9.05 Overall government revenues 100.00 100.00 100.00 100.00 100.00 100.00 2.4 Political context Sudan has a long history with decentralization dating back to 1951. Decentralization was introduced as a system of governance compatible with the needs of the multi-ethnic and multi cultural society of Sudan. Since 1991 the political and administrative structure of the country has been based on a presidential republic and a federal system. The system has passed through many stages of development until the Local Government Act 2003 was enacted, giving more authorities and responsibilities to the localities, particularly in the areas of health, education and development. Currently, there is a three-tier government system i.e. federal, state and local government. According to the the Comprehensive Peace Agreement (CPA) the Government of National Unity (GoNU) was formulated at the national level. An autonomus government for the South of Sudan (GoSS) is introduced as an intermediate level to oversee and coordinate the Sothern states affairs. This arrangement will continue for six years (from 2005), after which 7 Ibid, page 56-58 9 people of South Sudan will have the freedom to choose between North-South unity or an independent state through a referendum. The Darfur crisis, which has flared up in 2003, is still a challenge to the government and its partners. The signing of the Darfur Peace Agreement and the conduction of the D-JAM have brought hopes of resolution to the conflict and initiating a recovery process. However, the situation is still fragile. The effect of the crisis on achieving the MDGs cannot be overlooked. It is known that conflicts have great effects on the indicators of mortality and malnutrition as well as poverty and the livelihoods of resident populations. 2.5 Epidemiologic context Sudan not infrequently; experiences natural disasters including floods, heavy rains and drought. The epidemiological profile of the country is typical of Sub-Saharan African countries; malnutrition and communicable diseases dominate the health scene with high vulnerability to outbreaks. There is also emerging and re-emerging diseases, many of which are compounded by factors beyond the health system. The main causes of morbidity and mortality are infectious and parasitic diseases such as malaria, TB, Schistosomiasis, diarrhea diseases, ARIs and protein-energy malnutrition. Two weeks prevalence of diarrhea and ARIs is 28.8% and 12.4% respectively in under-five children8. Recent data and surveys have shown that non communicable diseases are emerging as a public health problem due to the change in socio-economic and lifestyle conditions. Hospital data shows increase in the number of cases. Recent data has come from the Sudan Household Health Survey 2006, the following table shows the prevalence of some of the non communicable diseases: Table 5: Prevalence of non communicable diseases (north Sudan 2006) Disease Percent Hypertension 1.5 Diabetes 1 Heart Disease .2 Cancer .0 Epilepsy .1 Asthma .6 Cataract .4 Mental disease .2 Source: SHHS, 2006 2.6 Health system: 2.6.1 Governance The health system is a three-tier system. The federal level is concerned with policy making, planning, supervision, co-ordination, international relations and partnership. The state governments are empowered for planning, policy making and implementation at state level while the localities are concerned mostly with policy implementation and service delivery including health, education, and development. An intermediate level (Ministry of Health South Sudan) is introduced in the south following the CPA. Currently there are 25 states, (10 of which constitute the Southern Sudan). Each state is administered by a Wali (Governor) with a cabinet of 5-7 ministries and 5-12 localities. The Localities are administered by a Commissioner. 8 SHHS, 2006 10 The decentralized system entails huge requirements on human and material resources. These are insufficient in most of the localities and states at the present time. There is an inherent problem with regard to resources distribution between the three levels of governance which rendered the local level feeble in service delivery. The frequent amendments and changes in the function and structure of the locality level is another factor affecting the development of a clear system of governance and organization. Central transfers are currently an important source of finance for the states and localities, however, its functionality and impact need to be austerely studied. Many partners are involved in health care provision. In the absence of a comprehensive strategic framework there is marked inefficiency, fragmentation of the health system and poor coordination between partners in the health arena. Primary Health Care has been adopted as the key strategy for health care provision in Sudan in 1978 and re-emphasized in the National Comprehensive Strategy for Health in 1992-2002 and in the 25-Year Strategic Health Plan 2003-2027. The Interim Constitution of the Republic of the Sudan, article 46, states the commitment of the Government to provide universal and free of charge basic health services. The recent FMOH policy indicates that the minimum package for PHC services should include; Vaccination of children (EPI), Integrated Management of Child Illnesses (IMCI), Reproductive Health (RH), essential drugs, nutrition, health education and treatment of common illnesses. The HMIS performance is weak, unreliable and fragmented. This was a result of poor administrations of the systems, under funding and inharmonious actions of different players in the health arena. Recognizing these facts, the FMOH has developed a plan to strengthen the Health Management Information System which will be financed through Health Metric Network (HMN). The strategy will further expand on this work and provide a framework for future development. Federal level (FMOH) States level (SMOH) Locality level (locality health administration) Teaching Hospitals and specialized hospitals Health facilities (State and RH hospitals Communities / household Lower level PHC facilities 11 2.6.2 Service delivery and system resources: Primary health care facilities include primary health care units (PHCU), dressing stations (DS), dispensaries, health centres and rural hospitals. In principle, PHC units are staffed by community health workers (CHWs), while dressing stations are staffed by a nurse and/or a medical assistant, and dispensaries are headed by a medical assistant. According to FMOH Health Facility Description and Renaming Policy, the minimum acceptable facility level for health services provision is now the Basic Health Unit which is structured and staffed to deliver the essential package of PHC services. PHC units and dressing stations are below the minimum standard and should be upgraded to become Basic Health Units. The health centre is the first referral level for the lower-level facilities. According to the standards, it is supposed to be headed by a physician (medical officer/GP). Lower level PHC health facilities (BHU and Health Centres) are supposed to be managed through and financed by the localities. Rural Hospitals are considered part of the PHC level and serve as secondary referral level health institutions. Each rural hospital is expected to have an average bed capacity of 40 to 100 beds and managed and financed by the State Ministry of Health (SMoH). Tertiary hospitals include teaching, specialized, and general hospitals- are located in State capitals and operated by the SMOHs. In addition, the FMOH operates 21 tertiary-level hospitals and specialized centres. Overall coverage by basic health services is low. Further, there are significant urban rural and regional disparities in the availability of health resources and services. Existing Health Facilities 2005* State hospital s Urban HCs Rural HCs dispensaries Dressing stations PHCU Functioning Non functioning Functioning Non functioning Functioning Non functioning Khartoum State 43 114 30 177 22 0 0 41 0 Gezeria 52 48 141 0 0 0 0 739 0 Sinnar 13 12 13 34 36 58 73 0 0 Blue Nile 13 13 3 32 8 47 35 23 22 White Nile 34 24 28 79 0 61 0 57 11 Red Sea 19 19 14 31 6 14 5 115 56 Gadarief 16 19 19 20 0 85 0 64 0 Kassala 10 37 23 94 10 33 10 89 10 Northern 26 6 62 145 20 46 13 11 3 R. Nile 28 49 116 68 11 71 17 31 14 N. Kordofan 16 43 2 90 0 77 0 318 128 S. Kordofan 10 54 2 55 30 0 0 120 52 W. Kordofan 10 10 15 32 0 31 3 149 112 N. Darfour 11 10 17 30 23 0 0 46 175 S. Darfour 10 18 0 43 0 11 0 295 0 W. Darfour 4 6 0 37 0 11 5 126 57 Upper Nile 9 10 0 16 0 0 0 43 0 Bhr Elgable 4 19 0 14 0 3 0 55 0 Unity 4 13 0 9 0 17 0 0 0 Buhyrat 3 0 0 0 0 0 0 0 0 Gongly 4 10 0 0 0 0 0 0 0 E. Equateria 5 13 0 14 0 34 0 47 0 W. Equateria 7 5 0 4 0 0 0 8 0 N. Bahar Elgazal 1 4 0 2 0 0 0 4 0 W.Bahar Elgazal 2 2 0 34 0 2 0 23 0 Warab 3 0 0 0 0 0 0 0 0 Total 357 558 485 1060 166 601 161 2404 640 * the numbers for south Sudan is not updated. 12 population per PHC facility 5,000 10,000 15,000 20,000 25,000 30,000 35,000 40,000 45,000 50,000 N or th er n R . N ile R ed S ea S . K or do fa n W hi te N ile K as sa la N . K or do fa n B lu e N ile G ez er ia K ha rt ou m S ta te W . K or do fa n S in na r G ad ar ie f N . D ar fo ur W . D ar fo ur S . D ar fo ur A health facility survey conducted in 2003 for inventory and quick assessment of infrastructure showed that the public health infrastructure network is relatively small amounting to (5,465) functioning health facilities. Many of the health facilities are either not functioning or not satisfying the minimum requirement (see table). The current health facility population ratios of one rural hospital for every 100,000 population and one health centre for every 34,000 of the population in the North are below the acceptable levels. The situation is even worse in the South where the ratios are one health centre per 75,000 population and one hospital per 400,000 population. The overall coverage with recognized health facilities (RH, HC, Dispensaries) is one Primary Health Care Facilty/ l4,400 population.. Given Sudan’s estimated population of 35.5 millions, the number of health facilities providing PHC services should be 7,000 health facilities (one facility per 5,000 population). There is therefore is a gap of more than 1500 new health facilities. Furthermore, there is a need to upgrade the existing lower health facilities (dressing stations and PHCU) to basic health units. The health system is markedly skewed towards hospital and tertiary care services. There has been increased focus on establishing hospitals during the past 10 years (their number increased from 253 in 1995 to 351 in 2004). The hospital/population ratio is 1/100,000. The number of hospital beds also increased from 22,444 in 1995 to 24,785 in 2004 (72 beds /100,000 population Table (6): Results of the Sudan Health System Survey 2004: No Description Percentage 1 PHC facilities not functioning 36.0 2 RHCs not functioning 16.9 3 Urban health centres not functioning 06.1 4 Dispensaries not functioning 30.0 5 Dressing stations not functioning 57.4 6 PHC units not functioning 51.1 7 PHC facilities need rebuilding 12.6 8 PHC facilities without constant supply of electricity 54.2 9 Health facilities with availability of safe water supply 26.9 10 Health facilities with sewerage system 79.1 11 Health facilities not satisfying the minimum requirement of equipment 53.8 12 Health facilities not satisfying the minimum requirement of furniture 37.3 13 Availability of laboratory services within the functional health facilities (RH,RHC,UHC) 73.0 14 Health facilities with fixed and functional vaccination centres 41.0 15 Availability of blood banks in rural hospitals 8.3 13 16 Availability of X-Ray services in rural hospitals 70.7 17 Availability of operation rooms in RHCs 98.7 Only 22% of the existing primary health facilities are providing the minimum essential PHC package. EPI is provided in 74%, IMCI in 20%, Nutrition services in 20% and ANC in 16% of health facilities. There is no well designed and functional referral system; the exceptions are the health insurance corporation and IMCI implementing health facilities Environmental health services: Most of the common morbidities and mortalities in the country are environment associated or related. The ten leading causes of morbidity which accounts for over 60% of reported attendances to public health facilities are related to the environment. Overall, 59.3% and 31.2% of the population has access to improved drinking water and improved sanitation facilities respectively. There is marked regional and urban rural variation in this regard9. The environmental health services are very weak in all states. Solid waste collection and disposal, food sanitation and inspection, drainage of rain water and sewage systems are very weak. This is further aggravated by the marked displacement and population movement which resulted in formation of un-healthy slums at the periphery of big cities and towns. Health education programmes as well are very weak. There is a huge gap in the personnel working in environmental health as shown in the table below; Table 7: Gap in environmental health personnel Category of health cadres No. available No. required Gap Public health officers 740 1,500 760 Sanitary oversees 948 4,500 3,652 Assistant sanitary oversees 1267 13,500 12,233 9 Sudan Household Health Survey, 2006 coverage with the PHC package 0% 10% 20% 30% 40% 50% 60% 70% 80% EPI IMCI Nutrition ANC 14 The Private Sector: The role of the private sector in providing health services is not well documented. However, the private sector has significantly expanded during the 1990s and the new century, particularly in the aftermath of implementation of the major macroeconomic and related sectoral reforms. The growth of the private sector is encouraged by the government policies. Private health services are mainly concentrated in urban settings and better-off states. Percentage of population using improved drinking water sources , SHHS, 2006 0 10 20 30 40 50 60 70 80 90 Percentage of population using sanitation facilities , SHHS 2006 0 10 20 30 40 50 60 70 80 90 15 Its focus is on curative services, and have little role in the provision of public goods such as preventive interventions, immunization and health promotion. Private health facilities at present contribute 17% of bed capacity, 36% of x- ray units and 54% of ultrasound units in Khartoum state. The systems and regulations that govern the private sector are poorly enforced. ترة م انشاؤها حسب الف المستشفيات الجديدة الخاصة بوالية الخرطوم التى ت الزمنية 0 5 10 15 20 25 30 70 71-75 76-80 81-85 86-90 91-95 96-00 2001-04 السنة ات ــفي تش مس ال ــدد ع Source: Khartoum State Ministry of Health Source: Federal Ministry of Health Annual Statistical Report 2004 Sudan Household Health Survey, 2006 showed that 19% of the health services users chose the private sector. The same result (18%) was reported by the Utilization of Health Services Survey, 2006. Issues and challenges concerning the private sector include; quality assurance, competition policies, price moderation, regulation and public private partnership. Public employees are allowed to practice in the private sector in their leisure time. This policy is abused by many of the workers where many of them work in the private sector during the official working hours. 2.6.3 Planning and management of human resources for health (HRH) Investing on HRH is considered a key issue for achieving MDGs and improving access to health services. The FMOH has recognized the importance of HRH for materializing the health system goals and improving the system performance. This is reflected in a number of policy documents developed to improve planning, production and management of HRH in the country. Further, Private Health Facilities In Khartoum State Compared to the other 15 Northern Sates, 2004 0 100 200 300 400 500 600 700 800 900 Hospitals Clinics Pharmacies N u m b er o f H . f ac ili ti es Khartoum State other states New private hospitals established in Khartoum State 16 availing a health workforce that can achieve optimum performance in delivering the required health services has been and will remain a key policy issue for the FMOH and praiseworthy efforts are dedicated to this end. The total health workforce is estimated to be around 62,483 health personnel classified into more than 20 categories. There are 8,379 physicians, 5,947 medical assistants, 17,923 nurses and 11,487 midwives (2005). Nurses to population ratio is 5.1 per 10,000, Physicians population ratio is 2.4 per 10,000. The attrition rate of physicians and pharmacists to the private sector and abroad is high. Only 8,379 physicians remain in the public sector out of the 17,000 registered in the Sudan Medical Council Registry since 1936 The gap in human resources is huge, especially for the nurses and medical assistant as projected in the 10-year human recourses strategic plan 2004-2013 (see table). Not only is the attrition rate of human resource high in Sudan as in many developing countries, the rate of production of human resources is low, especially for nurses and medical assistants (refer table 8 below) Table 8: Available Health Workers and Required by Category of workers Category Current Needed Gaps Specialized Doctors 1000 5000 4000 Nurses 18,000 80,000 62,000 Midwives 11,500 26,000 14,500 MAs 6,000 26,000 20,000 The share of PHC facilities in human resources is a small fraction of the total health workforce. There is immense inequitable distribution of health care providers between and within states, and between urban and rural areas. The main reason, inter alias, is the poor working environment in the rural and remote areas. The Federal Institutions and Khartoum SMOH facilities attract the majority of the country’s professional skilled health workforce. Even with the exclusion of house officers, still nearly two thirds (61.4%) of the doctors were stationed in Khartoum in 2004. Other professions of health workforce are also concentrated in Khartoum State. Production of HRH (Rate/100,000 Population) 0 10 20 30 40 50 60 70 1995 2000 2004 Doctors Medical Assistants Nurses 17 Many partners are involved in the training of health workers. These include the FMOH and other public institutions, the private sector and NGOs. The existing production level is far below the needs of the community for all professions. Presently, there is shortage of qualified health professionals in the country across the board, especially pharmacists, nurses and allied health personnel. Recently a marked expansion in higher medical education has occurred. Production of physicians seems to be much better than other professions and nowadays there are 30 medical schools; the annual production of doctors is estimated at 2,200. Regarding postgraduate studies, there are two training institutes for postgraduate medical specializations; the Postgraduate Board of Medical Studies, University of Khartoum (established in 1976) and the Sudan Medical Specializations Board established in 1995. The SMSB is currently the sole body responsible for postgraduate medical specializations in the country. The rate of annual intake is 97 and annual production is 48, which is far below the required numbers (500/year) estimated in the 10 year HRH strategic plan 2004-2013. The tables below summarize the intake and output of the SMSB since 1995 up-to 2005 Table 9: No. of students enrolled in SMSB in the period 1995-2006 Patch No. Starting date No. enrolled Patch No. Starting date No. enrolled 1st Apr. 95 49 10th Dec. 2001 80 2nd 1996 48 11th Jun. 2002 99 3rd 1997 29 12th Dec. 2002 24 4th Mar. 98 49 13th Jun. 2003 46 4th Oct. 98 39 14th Dec. 2003 59 6th Sep 99 67 15th Jun. 2004 78 7th May 2000 65 16th Dec. 2004 59 8th Dec. 2000 40 17th Jun. 2005 34 9th Jun. 2001 92 18th Dec. 2005 32 10th Dec. 2001 80 19th Jun. 2006 79 Total 1068 Table 10: No. of students graduated from SMSB till 2005 Patch No of candidates No. graduated Success rate (%) First 46 34 73.9 2nd 76 57 75 3rd 27 17 62.9 4th 42 31 73.8 5th 40 30 75 6th 33 21 63.6 7th 56 38 67.8 8th 46 32 69.5 9th 23 13 56.6 10th 62 27 43.5 11th 78 38 48.7 18 Total 529 338 63.8 There are 13 institutes for training of Medical Assistants (MA) and 38 midwifery schools with an annual production of 320 medical assistances and 1400 midwives respectively. There are 2 schools for health visitors and the annual production has recently increased to 80 health visitors (HV); a total of 625 health visitors have been trained till 2005 and many are in service. The trend shows a decline in enrolment due to the long training period and the unattractive financial incentives (health visitors are prohibited from conducting home deliveries, a source of income for village midwives). This issue is addressed in the recent human resource policy (Sudan Declaration). These institutes are currently upgraded to become branches of the Allied Health Academy. Continuous professional development and on-the-job training is limited to national training activities supported mainly by UN agencies. Recently the FMOH established a centre for continuous professional development. Policies and plans for on-the-job training and career development for different cadres were developed but not yet fully implemented. Recently a number of HR policies were developed and are in different stages of implementation. These include: Sudan Declaration for Nursing and allied Health workers Educational Reform (March 2001). This policy calls for “development and promotion of all nursing and allied health cadres by the year 2015”. This will result in phasing out of all institutes known to produce technical nurses and allied health personnel and upgrading them to higher educational institutes. Career pathway policy for medical doctors and allied health personnel which addresses many issues related to quality, performance and deployment. 2.6.4 Financing of Health Services: The financing of the health services has passed through successive reforms. From the colonial period till the beginning of the 1990, the health services were offered free of charge. User fees were introduced in the early nineties, as part of the econmoic sector reforms and adjustment. The impact of the introduction of user fees in public health facilities is not well documented, however anecdotal evidence suggests that the introduction of user fees has signifcantly affected access and utilization of health services with little or no significant improvement on the availablity and quality of care. To amilorate the negative impact of the introduction of user fees on accessing health services, emergency cases at hospitals are exempted from user fees. Other exemptions include renal dialysis, immune suppressant drugs for renal implantation, chemotherapy, radiotherapy and treatment of hemophilia. The annual expenditure on free treatment amounts to 3.5 billions SD (US$13.6 million) in 2005 (increased to US$19.4million in 2006 budget) equivalent to 15-22% of total federal health budget. Furthermore, prepaid sheme was introcuced as part of the health finanaicng reform in the mid ninties in the form of the National Health Insurance Fund to moderate the negative effect of user fees. About 5.4 million people are covered (15.3 % of the total population in 2005). In 2002, 76% of the covered populations were government employees, 4.2% were poor families, 2.8% were families of martyrs, 2.4% were students and 5.9% were members of the informal sector. 10 The general public expenditure on health has increased from US$ 295,738,819 in 2004 to US$ 474,729,913 in 2006. This level of per-capita spending is equivalent to US$ 9 and US$ 13 for both years respectively. 10 National Health Insurance Fund annual report, 2002. 19 Spending at the federal level is through FMOH budget (3-4 US$ percapita and social security funds (health insurance, Zakat fund, etc) which is equivalent to 1-2 US$ percapita. National Insurance Fund, covering around 15 percent of the population – predominantly civil servants and their families – is reported to spend up to $ 34 million in 2005 (US$ 1 per-capita/year). The magnitude of private out-of-pocket expenditure is estimated to be as high as 19-21 USD per capita equivalent to 70% of the Total health expenditure (THE), but the exact figures are unknown. Health spending at the state level varies from as low as 3.5 US$ per-capita annually in South Kordofan to as high as US$ 7.5 in Khartoum state with an overall average per-capita spending at the state levels of around US$ 5 per-capita for the northern States. Spending at locality level is not known but it is estimated to be in the range of US$ 1-2 per capita; signifying a very low level of public spending on PHC and key interventions11. In 2005, the external resource channeled through the the ministry of health amounts to 46.1 million US $ mainly from UN agencies. International NGOs contributed by 390 million $ in health and other huminaterian assistance in 2005. the exact amount spent on health care services is unknown. 2.7 MDGs 2.7.1 A- MDGs current status and trends Although the overall health indicators in Northern Sudan are poor, they are better than those of Sub-Saharan African countries, but worse than those of Middle East and North African countries. In addition, the national averages mask significant urban-rural and regional disparities due to conflict, displacement, and chronic poverty. The health indicators reflect a poor health system performance due to the above mentioned system constraints. The recently completed Sudan Household Health Survey shows that the national average of infant Mortality Rate (IMR) is 52/1000, U5MR 73/1000. MMR figure for north Sudan is 638/100,000. Deliveries attended by trained personnel are 68.3%. 11 FMOH, Health Economics Directorate Public Health Spending, 2006 FMOH $3.68 27% SMOHs $5.15 38% Localities $0.25 2% Armed Forces $2.68 20% Social Security Funds $1.73 13% 20 Table 11: Health-related MDG indicators12 Sudan Sub Saharan Africa Middle East & North Africa MDG 1: Poverty and Hunger prevalence of child malnutrition (underweight) (% under 5) 29.6 30 17 prevalence of child malnutrition (stunting) (% under 5) 31.3 42 23 prevalence child malnutrition (wasting) (% under 5) 13.7 8 7 MDG 4: Child Mortality under-5 mortality rate (per 1,000) 122 162 54 infant mortality rate (per 1,000 live births) 77 91 43 measles immunization (% of children 12-23 months) 62.7 53 86 MDG 5: Maternal Mortality maternal mortality ratio (per 100,000 live births) 638 1,100 360 Births attended by skilled health staff (%) 68.3 44 63 MDG 6: HIV/AIDS, Malaria, and Other Diseases prevalence of HIV (% adults ages 15-49) 1.6 9.2 0.3 contraceptive prevalence rate (% of women ages 15-49) 7 15 46 number of children orphaned by HIV/AIDS .. 11M 65,000 Proportion sleeping under insecticide-treated bed nets (% children under-5) 49.8 2 .. Proportion of children with fever treated with anti-malaria medicines (% children under-5 with fever) 50 42 .. incidence of tuberculosis (per 100,000 per year) 180 339 66 Tuberculosis cases detected under DOTS (%) 44.3 .. .. MDG 7: Environment access to an improved water source (% of population) 59.3 55 90 access to improved sanitation (% of population) 31.2 55 83 General Indicators Population 35.5 M 674 M 300 M total fertility rate (births per woman ages 15-49) 5.9 5.1 3.3 Life expectancy at birth (years) 57.9 46.2 68.2 The above table shows the national averages, further analysis shows that the national averages disguise significant inequalities and poor health situation at the state level. There has been little improvement in the MDG indicators over the 1990s. This requires scaling up of interventions and significant efforts to get on track for achieving the MDGs by 2015 2.8 Goal 4: Reduce child mortality SHHS figures indicate high National child mortality rates. The IMR and U5MR are 77 and 122 per thousand live births. No national base line figure for child mortality in the country, however, in the North, the decline in child mortality rates has been rather modest between 1990 and 2006. The infant mortality rate per 1,000 live births reduced from 801 to 712. Similarly, the under-5 mortality rate per 1,000 live births declined from 1433 to 1124 deaths with an average decline of 1.9% per year. Marked disparities in infant and under-5 mortality rates are evident between states. The trend line shows that the probability of achieving the MDGs targets regarding child mortality is unlikely if current trend persists. 12 1999 SMS and 2000 MICS in northern Sudan, Sudan National Tuberculosis Control Program (2003), UNAIDS (2002), Sudan Central Bureau of Statistics (2001), Sudan National AIDS Control Program (2002), and World Bank (2002). 21 Treand in U5MR (North) 0 20 40 60 80 100 120 140 160 1 2 3 4 5 U5MR MDG target Linear (U5MR) Trend in IMR (North) 0 10 20 30 40 50 60 70 80 90 1990 1999 2006 2011 2015 ra te / 1 00 0 IMR MDG target Linear (IMR) U5MR (2006) 0 50 100 150 200 250 N orthern U nity G ezira R iver N ile K assala N orth K ordofan N orth D arfur K hartoum E ast E quatoria W hite N ile U pper N ile C entral E quatoria S outh D arfur S innar Jongoli Lakes S outh K ordofan W est D arfur G adarif W est B ahr A l G azal R ed S ea N orth B ahr A l G azal W arab B lue N ile W est E quatoria IMR (2006) 0 20 40 60 80 100 120 140 22 Table 11: Child mortality by State/ Region,: (North Sudan) State regions NMR 1990 DHS IMR 1990 DHS CMR 1990 DHS U5MR 1990 DHS NMR 2000 IMR 2000 SMS U5MR 2000S MS NMR 2006 SHHS IMR 2006 SHHS U5MR 2006 SHHS Khartoum Khartoum 38.2 77.3 33.3 108 27 69 103 65 100 Red Sea Eastern 53.3 96.8 90.6 178.6 50 116 148 91 148 Kassala 38 101 148 54 81 Gadarif 31 67 117 87 139 Gezira Central 34.9 62.3 63.4 121.7 21 43 59 45 66 White Nile 33 70 111 68 106 Sinar 24 51 8 74 117 Blue Nile 46 101 172 114 191 North Kordofan Kordofan 41 74.8 64.4 134.4 28 60 94 60 92 South Kordofan 29 95 147 85 136 West Kordofan 34 72 95 North Darfour Darfour 55.1 90.8 77.3 161.1 27 61 101 60 92 South Darfour 33 64 96 71 111 West Darfour 42 71 104 85 136 River Nile Northern 36.8 70.6 45 112.5 29 57 81 46 68 Northern State 26 56 78 38 54 Table 12: Child mortality by State,: (South Sudan) State NMR 2006 SHHS IMR 2006 SHHS U5MR 2006 SHHS Unity 25 45 65 Central Equatoria 38 68 107 East Equatoria 26 67 104 Jongology 88 79 125 West BahAlghazal 22 88 141 Lakes 44 84 135 Warab 43 100 165 North NahrAlghazal 57 99 163 Upper Nile 112 68 106 West Equatoria 73 129 218 Analysis of the out patient case load in health facilities revealed that the majority of outpatient case load among under-five children is due to diseases including Malaria, Pneumonia with other ARI s, Diarrhea, Malnutrition and Measles13. Protein Energy Malnutrition (PEM) and Micronutrients deficiencies are the most common problems that affect children under five years of age and women. The nutritional indicators are still poor; the SHHS shows that underweight prevalence is 31 % and stunting is 32.5 % and those who are wasted are 14.8% (-2 SD). Significant inequalities are evident between states, for instance the stunting prevalence ranges 8.2% in Gezira state and 30.9% in Unity state. The same inequalities are found in the prevalence of underweight and wasting. The situation has improved compared to the figures of MICS, 2000 as shown in the table below: Table 13: Under five child malnutrition Indicator SHHS, 2006 MICS, 2000 2 SD -3 SD - 2SD - 3 SD Weight/ Age 31 % 9.4% 40.7% 14.7% Height/ Age 32.5 % 15.2% 43.3% 23.7% Weight/ height 14.8% 3.5% 15.7% 3.8% 13 Federal Ministry Of Health, Annual Statistical report, 2004 23 percentage of under-five children who are severely or moderately undernourished, (weight for height) Sudan 2006 0 5 10 15 20 25 30 35 Ge zir a Ce ntr al Eq ua tor ia Ga da rif W es t E qu ato ria So uth D ar fur Kh ar tou m Si nn ar Bl ue N ile W hit e N ile So uth ko rd ofa n No rth ko rd ofa n La ke s Ri ve r N ile Re d S ea Ka ss ala Ea st Eq ua tor ia W es t D ar fur No rth D ar fur W es t B ah r A l G az al W ar ab Jo ng ole i Up pe r N ile No rth B ah r A l G az al Un ity tot al Two weeks prevalence of diarrhoea is 28.8% in under-five children14. Oral Rehydration Therapy use among children with diarrhea is 58.5% and children who increased fluid intake during the episode of diarrhea are 26.1%. SHHS, 2006 showed that, the two weeks prevalence of ARIs is 12.4% in under-five children15. Of them 74.3% received treatment from an appropriate care-giver. Breast feeding indicators showed some improvement in comparison to MICS 2000 results as shown in the table below.. Table 14: Breast feeding Indicator MICS, 2000 SHHS, 2006 Exclusive breast feeding in children aged 0-3 months 21.4% 42% Exclusive breast feeding in children aged 0-5 months - 33.5% Complementary feeding in children aged 6-9 months 46.6% 55.5% Continued breast feeding in children aged 12-15 months 83.5% 83.4% Continued breast feeding in children aged 20-23 months 40.4% 34.9% Surveys conducted in states during the period of 1997 to 2001 showed that night blindness due to Vitamin A deficiency ranged from less than 1% to 4.8%. According to SHHS 67.1% of the children under-five received one dose of Vitamin A within the last 6 months. 14 SHHS, 2006 15 SHHS, 2006 Percentage of children 6-59 months of age who have received a high dose vitamin A supplement in the last 6 months, Sudan, 2006 10 20 30 40 50 60 70 80 90 100 Jo ng ol i N . B ah r G az al U pp er N ile La ke s U ni ty W ar ab W . B ah r G az al W . E qu at or ia E. E qu at or ia C . E qu at or ia S. K or do fa n S. D ar fu r K as sa la R iv er N ile W . D ar fu r W hi te N ile R ed S ea N . D ar fu r K ha rt ou m G ez ir a N or th er n N . K or do fa n Bl ue N ile G ad ar if Si nn ar Su da n 24 Data on the national prevalence of Iron Deficiency Anaemia is not available The iodine deficiency goitre rate was 22% in 1997. The consumption rate of iodized salt is 0.6 % and 0.5% in Northern and Southern states respectively (MICS 2000). Various strategies and interventions are used to control micronutrients malnutrition, including supplementation, food diversification and public health measures. Sudan has adopted food fortification strategy as a long term intervention. The Expanded Program on Immunization (EPI) has recently achieved the national target of DPT3 coverage (83% in 2005). Polio, measles and MNT campaigns supplement the routine programme. Sudan Household Health Survey data showed that many of the northern states achieved significant success. However, all of the southern states are lagging behind (11.8% in Lakes state to 35.4% in Upper Nile state) making the national average of DPT3 coverage only 50.9%. With funding from GAVI ALLIANCE, the EPI introduced Hepatitis B vaccine the 15 Northern states. It is estimated that 33% of the population receive immunization from fixed posts, 27% from mobile teams and 40% through outreach activities. In some remote and conflict prone areas, the population is entirely dependent on NGO services for immunization. The Acute Flaccid Paralysis (AFP) surveillance system, established by the EPI in 2001, has maintained a satisfactory performance, with all indicators meeting international certification standards. Proportion of children 12-23 months of age immunized against Measles, SHHS, 2006 0 10 20 30 40 50 60 70 80 90 100 Jo ng le i N . B ah r G ha za l W . B ah r G ha za l W ar ab Ea st Eq ua to ria La ke s S. D ar fu r U pp er N ile U ni ty W . E qu at or ia Re d Se a W . D ar fu r S. K or do fa n C. E qu ato ria Bl ue N ile N . K or do fa n W hi te N ile N or th er n G ed ar if K as sa la N . D ar fu r Si nn ar Ri ve r N ile K ha rto um G ez ira Su da n 25 Main partners of the EPI are WHO, UNICEF and some NGOs. GAVI ALLIANCE five-year support started in 2002. The Government is mainly financing the salaries of the permanent EPI staff at all levels (federal, state, locality, health unit), and supporting the programme with transportation and other logistical issues. IMCI was introduced in the year 1997 as an initiative to integrate the child health services. Since early implementation, the program has expanded to cover 1,148 health facilities in 43 localities in 16 states, 15 of them are Northern States. IMCI community component has been introduced at a limited scale in 25 communities. The results of the IMCI health facility survey (March 2003), revealed that 73% of the surveyed children were seen in dispensaries run by medical assistants (MAs), this will entail a focus on building the capacity of MAs providing health care to under five children. The same survey has shown that the performance of IMCI trained health workers was much better than those who are not trained. The proposed Accelerated Child Survival Initiative offers the opportunity for Sudan to achieve this goal on or before the target date of 2015. 2.9 Goal 5: Improve maternal health: Progress towards achieving goal 5 is assessed through examining three indicators: the maternal mortality ratio (MMR) the contraceptive prevalence rate and the proportion of births assisted by skilled birth attendant. Between 1990 and 1999, the MMR reduced from 552 to 509 maternal deaths per 100,000 live births16, a decline of 7.8% which is not that significant. There are also wide disparities and inequalities, both between regions and within regions. The preliminary findings of the SHHS from north Sudan showed considerable improvement in Khartoum, Kudrufan, central and northern states. But the conflict affected states showed considerable deterioration, particularly Darfur and eastern states. These ratios are better than those in many countries in sub-Saharan Africa, but they are the worst in the Eastern Mediterranean region. The results of maternal mortality for southern states is not yet available, however, current estimates are as high as 1700/100,000 live births. Due to the poor indicator in 2000, Sudan was selected by EMRO-WHO as one of the countries to in EMR to implement Making Pregnancy Safer initiative. Table 15: Maternal Mortality State MMR 1999 SMS (regions) MMR 2006 SHHS ((regions) MMR 2006 SHHS Khartoum 559 311 311 Red Sea Eastern 556 Eastern 854 166 Kassala 1413 Gadarif 609 Gezira Central 452 Central 400 355 White Nile 366 Sinar 320 Blue Nile 514 North Kordofan Kordofan 582 Kordofan 352 212 South Kordofan 503 North Darfour Darfour 524 Darfour 1255 346 South Darfour 1580 West Darfour 1056 River Nile Northern 319 Northern 137 160 Northern State 93 16 CBS, 1990 26 In 2005, 11,487 village midwives were working in the country (in addition to 3000 TBAs). The converge is one village midwife fro 3,180 of the population. Presently 38 Mid-Wifery institutions, (29 of which are adequately functional) are training mid-wives, with an estimated 1,400 trained every year by the 38 schools. Training manuals of midwives curriculum are not up to the standard needed for Skilled Birth Attendants (SBAs). The FMOH has recently revised the curriculum and training methodology. There are 166 permanent teachers (health visitors) in these schools. Most of them do not possess the required teaching skills and qualifications. About 57 % percent of births occurring in the year prior to the SHHS were delivered by skilled personnel (57% in 2000). This percentage is highest in the Northern state at 98.2 percent and lowest in Jongoli State at 22 percent. Midwives assisted 29.8%, doctors assisted 11% and nurse midwives assisted 16 % of deliveries. Institutional deliveries accounts for only 19.6%. Only 50% of the rural hospital doctors are trained in EmOC, in spite of the fact that the course has been conducted in all states during the last 3 years. This is due to the rapid turnover of doctors resulting from the unattractive working conditions. According to the national EmOC need assessment report in 2005 only 47% of hospitals are providing adequate comprehensive EmOC services. In 1999, 7% of the currently-married women were using any form of family planning methods (a decline of two percentage points since 1989/90). However, unmet need for contraception is clearly evident, for example, 11% of women indicated that their births were unplanned and another 4% said that they were unwanted; the percentage of those who have ever used contraceptives was 21%17. A similar figure is shown in the SHHS, 2006 (7.7%). There was variability between States in the percentage of women currently using any method of contraception where the highest percentage is found in the Northern State (20%) followed by Khartoum State (18.6%) the least was in Jongoli (0.2%) followed by West Darfur (0.9%). The total fertility rate (TFR) has fallen from 5.9 in 1999 to 5.1 in 2006. The total fertility rate is the highest rates in the Eastern Mediterranean region and comparable with many countries of Sub Saharan Africa. About 70 percent of women in northern Sudan and 90 percent in the three Southern towns receive antenatal care from skilled personnel (doctor, health visitor, midwife trained TBA) in 2000. The national level increased to 92.6% in 2006. Doctors delivered ANC to 33% of pregnant women, nurses to 11.8% , midwives to 17.9, TBAs to 2% and CHW to 0.6%. 17SMS, 1999 Proportion of births attended by skilled health personnel, SHHS, 2006 0 10 20 30 40 50 60 70 80 90 100 W . D ar fu r E. E qu at or ia Bl ue N ile S. D ar fu r Jo ng ol ei S. K or do fa n C .l Eq ua to ri a K as sa la La ke s G ad ar if N . B ah r A l G az al Si nn ar N . D ar fu r N . K or do fa n R ed S ea W ar ab U pp er N ile U ni ty G ez ir a W . B ah r A l G az al W hi te N ile K ha rt ou m R iv er N ile W . E qu at or ia N or th er n Su da n 27 In the southern states most women and their infants were not protected against tetanus. Most women also did not receive antenatal care during their last pregnancy. There were wide variations in ANC services in different regions. Only 21.1% of women have received antenatal care during their last pregnancy. Most deliveries in southern Sudan are conducted by untrained TBAs, 77.7% of deliveries were conducted by untrained TBAs18. No information is available on postpartum care except that 8.9% of women were given Vitamin A capsule within 40 days of delivery. The midwifery services at village level are largely provided by untrained TBAs. The other providers are Maternal and Child Health Worker (MCHW) who receive 9-months training and there are about 213 of them involved in the provision of maternal services at primary healthcare units and primary healthcare centers. 2.10 Goal 6: HIV/AIDS, malaria and other diseases 2.10.1 HIV/AIDS control and prevention Sudan is a signatory to the Declaration of Commitment made at the United Nations General Assembly Special Session on HIV/AIDS (UNGASS) in June 2001, The Millennium Development Goals, September 2000, the Abuja Declaration and Framework for Action on HIV/AIDS, tuberculosis and Other Related Infectious Diseases adopted at the African Summit and the International Conference on Population and Development. Each of these declarations recognizes the potential threat posed on Global and National Development by the AIDS pandemic, seeks Government’s commitment and calls for a better and comprehensive response to combat the pandemic. At country Level, the National Population Policy, this document, the 5Yr Health Sector Strategy and Investing in Health to achieve the MDGs, and the National Health policy give special emphasis and priority to HIV/AIDS control interventions. Epidemiological studies conducted as part of the national Situation and Response Analysis, September 2002, showed that the country is classified to be in an early stage of a generalized epidemic. The prevalence rate was 1.6% among the general population19. There are, however, regional variations: the prevalence of HIV infection is higher in the Southern states, Eastern states, Khartoum and White Nile States. Heterosexual transmission accounts for 94% of the reported cases, while vertical transmission from mother to child accounts for 2.4%. At the end of 2005, the number of reported cases since the beginning of the epidemic was more than 12,000 HIV /AIDS cases. Sentinel Sero-Surveillance for pregnant women attending antenatal Clinics (ANC), clients seeking treatment of tuberculosis (TB) and clients seeking treatment of Sexually Transmitted Infections (STIs) is carried in 26 selected sites. The data collected through the sentinel sites in 2004 – 2005 showed huge regional variability where a relatively higher prevalence reported from Khartoum, east and south parts of the country. Among the population segments tested data showed a prevalence range of 0.5- 1.5% among pregnant women and 1.5- 2% among STIs and TB patients. Sudan’s situation is made even more difficult by the epidemic taking a grip in neighboring countries with the free movement across the porous borders. 18 MIC S, 2000, 19 Behavioural and Epidemiological Survey Report, 2002 28 The number of reported AIDS cases is showing an alarming increase from year to another as shown in the figure below20 Figure 1: Annual Reported AIDS Cases 1986 - 2005 In response to the situation, during the last 2 decades the main focus of the HIV/AIDS Control Programme was on blood safety, sexually transmitted infections and small scale awareness and advocacy program. The limited donor support was shaped around these priorities in addition to limited support to condoms distribution and people living with HIV/AIDS. Other elements of response such as care and treatment, voluntary counseling and testing, disease surveillance and support to multisectoral response have not been considered until recently. This obvious shortcoming in the national response could be attributed to the lack of resources and commitment in the early stage of the epidemic. Starting from 2001 onwards, dramatic improvement has been observed in the National AIDS Response. This is largely a result of the strong advocacy and ‘Breaking the Silence Campaign’ that was led by the National AIDS Control Program and engaging different partners including the religious leaders, donors, UN agencies, NGOs, line Ministries and the private sector. The campaign has contributed to the end of the denial stage and different partners and the government recognized the need for stronger and evidence based AIDS response. The National Strategic AIDS Plan development started and included four stages: situation analysis, response analysis, plan development and resources mobilization. The steps were completed successfully apart from the resources mobilization with Sudan suffering huge resource constraints in covering the cost implications of the plan at that time. Another key feature of the national response is the development of a national policy on HIV/AIDS that addresses different issues related to HIV/AIDS including the Rights of People Living with AIDS, stigma, discrimination, gender, roles of different sectors, research, legal issues, and needs of most at risk groups plus other issues. 20 Hospitals Data, reported in the SNAP repots Annual Reported AIDS Cases 0 1000 2000 3000 4000 86 - 89 90 -94 1995 - 1999 2000 -2005 Years No. of Cases 29 At the partnership level, more stakeholders from government, NGOs, donors and private sector became involved in the HIV/AIDS field. The mechanisms for this partnership have been through formulation of different forums such as the National AIDS council which includes representation from different Ministries and key actors. Other mechanisms were also formulated; one example is the Country Theme Group on HIV/AIDS led by UNAIDS to ensure coordination between the UN, Government and the private sector. Moreover The Global fund process has resulted in stronger Public–Private Partnership to combat the three major killers in Sudan: TB, Malaria and HIV/AIDS. The Sudan AIDS Network, an umbrella forum for NGOs working in HIV/AIDS has also been activated to ensure effective partnership and coordination among NGOs resulting in the increase in numbers of NGOs working in the AIDS field. At the service delivery area, more interventions targeting both the general public and most at risk population segments are now in place. For instance, the number of VCT centers has increased from only one in 2001 to more than 45 in 2006 and the number of treatment centers has increased from only one in 2001 to 14 in 2006. More Health providers have also received comprehensive training and the number of staff capable of treating AIDS patients has increased from only three 2001 to more than 500 according to the training reports of the National AIDS program. Prevention of mother to child transmission (PMTCT) services has also been initiated in three priority states of the country and more women are now receiving AIDS counseling and testing within the ANC settings. With regard to prevention activities the level of awareness has improved; MICS (2000) showed that 40 percent of women aged 15-24 in northern Sudan and 67 percent in the towns of the south have heard of AIDS compared to 69.7% as shown in the Sudan Household Health Survey, 2006. SHHS also showed that 44.1% of women aged 15-24 can correctly identify at least one method of preventing transmission of the virus compared to 25% and 31%, in north and south in 2000 (MICS, 2000). The comprehensive knowledge about HIV Prevention (Proportion of young women aged 15-24 years who both correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission) is about 11% compared to 2% in 2000 (MICS, 2000). Other recent features are the initiatives taken by some key governmental sectors to incorporate HIV/AIDS in their plans and mandates through nomination of focal points and establishment of HIV/AIDS units within their structure. A good model of these initiatives is the partnership developed between Ministry of Health, UNICEF and Ministry of Education to include Life-Skills based curricula in primary and secondary schools targeting more than 2,400,000 school pupils and their families. Another good initiative is demonstrated by the Ministry of Defense and Ministry of Interior which have introduced HIV testing and treatment within their health facilities and initiated awareness raising and peer education among the uniformed services. The Ministry of Higher Education is also working through 12 Anti-AIDS Students Associations in large universities to improve AIDS prevention among university students and the surrounding community. Other line Ministries that have become part of the National Response include Ministry of Social Welfare with focus on Orphans and Vulnerable Children, Ministry of Labor and Administrative Reform with emphasis on HIV in the work place, Ministry of Youth and sports with focus on Young people and Ministry of Justice with focus on Rights of People Living With AIDS and support to a special law on HIV/AIDS Supporting environment and policies: The FMOH has taken the leadership in creating and supporting an enabling and favorable environment for a better response to HIV/AIDS. The Country leadership at the highest level showed greater commitment to fight the HIV/AIDS threat. The President has launched the National Strategic Plan and directed the relevant government departments to give high priority to 30 AIDS control and prevention efforts. The Federal Minister of Health who is the Chair of the National AIDS Council is closely working with other sectors to ensure the involvement of other line Ministries in the overall response. The policy and planning environment for HIV/AIDS programming has substantially improved in the last years and the Ministry of Health has developed a number of short- and long-term HIV/AIDS plans of Action. These cover a wide range of strategies and interventions such as behavior change communication including life skills training for young people, service packages for most at risk groups such as refugees, uniformed personnel, prisoners and other risk groups, VCT services; blood Safety, Care and support for People Living With AIDS, surveillance ,and capacity building for staff working on HIV/AIDS. Huge efforts are done to build the capacity of the State AIDS Programs through training of staff and logistical support in terms of supplies and IT equipment. To support the policy environment the program is also undergoing Monitoring and Evaluation (M&E) enhancement process through support from UNAIDS. An M&E Framework is now being developed, it includes more than 50 national indicators that are identified through continuous consultation and input of different partners from UN, Donors, government, academia, private sector and state AIDS programs. The overall goal for the period 2004-2009 is to reduce/contain the prevalence to less than 2% of the general adult population, while avoiding the stigmatization of vulnerable populations. To achieve this goal, the government in partnership with other Country Coordination Mechanism (CCM) members has submitted an application to the Global Fund to Fight TB, AIDS and Malaria (GFATM) round 3, now on the implementation process, and round 5, which is approved but not yet signed, with a total fund of 20 millions and 112 millions respectively. It is expected that the GFTAM would contribute to the achievement of different targets identified in the National Strategic Plan and enhance public private partnership for better program implementation and coordination. Despite these improvements, some obstacles remain and might affect the program absorption capacity. These obstacles include capacity at National and State level, M&E, Procurement and supply systems and human resources issues. Moreover there are still funding gaps in some areas like the program for most at risk groups and support to the multisectroal response. 2.10.2 Malaria control – status and trends Malaria is endemic throughout the Sudan. Endemicity varies from hypo-endemic in the North to hyper-endemic and holo-endemic in the South. Worth mentioning is that 80% of the population is living in epidemic-prone areas (unstable malaria transmission). The disease is caused in more than 90% of cases by Plasmodium Falciparum although other species also exist. Annually, malaria is estimated to have around 7.5 million attacks of sickness and to kill around 35,000 people. At public-sector health facilities, malaria accounts for about one-fifth of outpatient attendances and in public-sector pediatric hospitals the case fatality rate ranges from 5% to 15%. The caseload has been reduced somewhat in recent years. Between 1993 and 2004 the annual parasite incidence per 1,000 people fell from around 400/10,000 to 60/10,000, and have been declining since then. The figure below shows the trend of reported Malaria cases per 1000 of the population for the period 1999-2004 31 Table (): Reported admissions, deaths due to Malaria (2000-2004) Year Admitted Malaria cases Deaths CFR 2000 119,256 2,379 1.99%, 2001 196,575 2,502 1.27%, 2002 204,249 2,757 1.35%, 2003 152,686 2,479 1.60% 2004 130,585 1,814 1.26%. Malaria treatment protocol has been changed from Chloroquine to Artemisinin-based combination therapy (ACTs) based on research evidence. The new drug is readily available in public health facilities and market. The new drug is provided to the patients free of cost in ten states under Global Funds arrangements. New treatment protocols have been developed in English and Arabic in the shape of booklets and posters and provided to health facilities. About 30% health facility staff has been trained on the new treatment protocols The programme has undergone successful structural reforms both at central and local levels. 19 states managed to attract and retain at least one trained coordinator (Diploma holder). Out of 96 targeted state cadres, 58 have been trained in Malarialogy Diploma course. Advance training in programme planning was given to 8 coordinators. Six entomologists have also been trained. Refresher training and short courses are regularly conducted. Now, around 40% of the states have adequate capacity to implement the interventions without significant support from the central level and another 40% are on the process of development. At least one vehicle has been provided to all northern states of Sudan for Malaria Control Program. Use of ITNs is one of the key components of Roll Back Malaria Strategy. The Government has waved off 60% of the duty and allowed duty free import of these nets. Coverage of nets has significantly increased during the last few years as 712,000 five year long lasting nets have been distributed free of cost. The results of a survey conducted in 10 states -2 of them are in the south showed that households with at least one mosquito net reached 57%. The Sudan Household Health Survey 2006 showed that 49.8 percent of children under the age of five slept under any mosquito net the night prior to the survey. Biological vector control has also been initiated in four states by using Gambosia fish. In the area of Monitoring and evaluation, there is a functioning system for weekly reports in 16 states with an effective feedback mechanism. Reported Malaria cases per 1000 of the population for the period 1999-2005 0 20 40 60 80 100 120 140 160 1999 2000 2001 2002 2003 2004 2005 32 Malaria Control Program has been active in conducting research and developing evidence based policies and strategies. 9 research papers have been published in renowned international journals. 2.10.3 TB control – status and trends Sudan occupies the third place in the EM region in relation to the incidence of TB, exceeded only by Pakistan and Afghanistan. It accounts for 8% of the region’s total TB burden21. The National TB programme has been implemented in 22 out of the 26 states. The remaining states are covered by NGOs through the Horn of Africa Initiative22. The annual risk of infection is estimated at 1.8%, of which around half are smear-positive. The total case load is estimated to be around 50,600 cases, half of it is notified. In the year 1999, maximum case notification was reached (26,950), but since then, case notification showed a gradually declining plateau. In 2005 the case detection rate was 44.3% which is far below the global target of 70%. The majority of TB patients are in the productive age of their life (15-45 years). There is also a strong link with HIV/AIDS; over the period 1988-96, 6% of TB patients were found to be HIV-positive. TB accounts for 12% of hospital admissions and is one of the main causes of hospital death. The DOTS- strategy was introduced in model areas in each state in 1996 and was gradually expanded. DOTS ALL OVER was declared in the year 200223. However, the rapid assessment of the National TB programme (NTP) conducted August 2006 showed that no health facility is complying with the DOT component of the strategy. Most of the DOT centres prescribe treatment for a week or a month. This was attributed mainly to the stigma associated with the disease or to the difficulty for the patients to come on daily bases to receive the treatment, especially when there is no near by health facility. In 2004, the treatment success rate has reached 81.9%, close to the global target. The cure rate is only 52% because a lot of the patients completed the treatment without being checked for cure (29%). In addition, the conversion rate of sputum at the second month is 85% (15% of patients not investigated). The defaulter and transferred out rates are 9.6% and the failure rate was 2.7%24. The TB Control program is receiving considerable funds through different partners including Norwegian Heart and Lungs Association, Global Fund and WHO. The drugs and consumables are available at all levels. The local component needed for administrative and supervisory activities is insufficient. The rapid assessment showed as well marked weaknesses in the hierarchical set-up especially at locality level, high turnover of trained personnel, poor registration and reporting and poor training and motivation of health facility workers. 21 WHO, 2002. Annual TB Report 22National Tuberculosis Program (2004): 2Nd In-Depth Review of National Tuberculosis Program of Sudan. 23National Tuberculosis Program (2004): 2Nd In-Depth Review of National Tuberculosis Program of Sudan. 24National Tuberculosis Program (2004): 2Nd In-Depth Review of National Tuberculosis Program of Sudan. 33 Table 16: TB programme, Case finding Summary 1993-2005 Year Pulmonary Extra Pulmonary Total Smear Positive Smear Negative New Relapse 1993 897 39 170 167 1,273 1994 3728 513 6,471 2154 12,866 1995 8761 604 3,001 1,954 14,320 1996 8978 1,185 7,641 2,476 20,280 1997 10835 1,652 5,859 2,548 20,894 1998 10820 1,655 6,901 3,442 22,818 1999 14075 1,806 6,933 4,136 26,950 2000 12440 2,159 6,600 3,892 25,091 2001 11136 1,776 7,071 4,014 23,997 2002 10338 1,657 7,871 4,713 24,579 2003 11003 1640 7802 4666 25111 2004 11236 1600 7798 4012 24646 2005 11143 1552 8355 4501 25551 2006(3rdQ) 7951 528 1786 1111 5739 Total 133341 18366 84259 43786 274115 Table 17: TB programme, treatment results year Cure Comp Die Fail Def Trans Total Cur Rate Com Rate Succ Rate 1995 3664 2882 177 591 890 122 8312 39.1 30.7 69.8 1996 2405 1705 187 246 971 192 5688 23.7 16.8 40.5 1997 3349 1674 301 280 1201 407 7212 26.8 13.4 40.2 1998 3710 1846 494 402 1735 339 8526 29.7 14.7 44.4 1999 6022 4544 661 298 1110 583 13214 37.9 28.6 66.5 2000 6344 3100 540 237 1266 675 12162 50.9 25.2 75.8 2001 6621 3381 494 85 862 462 10905 59 21 80 2002 6434 2135 367 67 803 263 10069 62.2 20.6 82.8 2003 6692 2236 326 103 1057 389 10803 60.8 20.3 81.1 2004 6819 2396 303 91 852 259 10720 60.6 21.3 81.9 Total 52034 24812 3849 2400 10746 3690 97531 2.10.4 Schistosomiasis & STH control – status and trends Schistosomiasis is endemic in different areas of the Sudan to varying degrees. It is the second major public health problem. In the years 2004 and 2005, the Federal Ministry of Health (FMoH), has conducted many epidemiological surveys. The prevalence rates of intestinal Schistosomiasis in sugar cane and irrigation schemes are very high, 53,7% (Asalaya ), 44,3% (Gunaid ), 55% ( New Halfa ), 43% ( Sinnar ), 48,7% ( Managil ), and 60.8% ( Rahad ). The reports of Schistosomiasis Control Program (NSCP) suggested that the disease burden has dramatically increased. The World Bank, Utroska et al. (1997) estimated that the minimum population at risk in the Sudan was 24 million, while 5 million are infected, with an average prevalence of 20.8%. On the other hand the government political and financial commitment and support both at the Federal and state levels have been insufficient and far below the challenge. 2.10.5 Leishmaniasis: Visceral Leishmaniasis is a vector born disease, transmitted by sand flies. The disease is endemic in Sudan and affects 7 states (Gedaref, Sinnar, Upper Nile, blue Nile, south kordufan, south Darfur and Unity). About 8,000-14,000 cases are notified yearly through 19 diagnostic and 34 treatment centres. These figures are under-estimates of the real burden due to the limited diagnostic and treatment centres which covers 5 states only (Gedaref, Sinnar, Upper Nile, Darfur and Unity). It is a seasonal disease with a peak during November – February. The first line drug of treatment so far in Sudan is Sodium Stibo Gluconate (SSG), the reports showed an evidence of presence of some resistant strains. 2.10.6 Lymphatic Filariasis Lymphatic Filariasis (LF) is a mosquito- transmitted parasitic infection widely prevalent in over 83 tropical and subtropical countries. The disease affects 120 million persons with 2 billion being at risk of contracting the infection. It is ranked as the second leading cause of permanent disability worldwide. The manifestations of Lymphatic Filariasis are enlargement of the entire leg or arm, the genitalia, breasts and internal damage to the kidneys and lymphatic system. The psychological and social stigmas associated with the disease are immense. In the period December 2003 to December 2006 epidemiological mapping was curried out in 63 localities (in 12 states) using rapid immunochromatographic card test (ICT) for Wuchereria bancrofti. The prevalence rate of the disease ranges from 1% to as high as 54% in Amatong County (East equatorial State, Southern Sudan) Table 18: LF prevalence per state: 2.10.7 Sleeping Sickness Human African Trypanosomiasis is a systemic protozoal disease transmitted to man by the bites of infected tsetse flies. It is endemic in south Sudan, particularly (central, West & East Equatoria). It is one of the most killing diseases in Equatoria Zone. In the past the control activities have been limited to few surveys and treatment of self reported cases. In 1999 a prevalence of 19.5% and 30.3% was reported in East Equatoria and central equatoria states respectively. In 2001 Sero-positive cases, using CATT and CIAT test shows rates of 43.9 and 48.1% respectively In central equatoria state. 2.10.8 Guinea Worm (Dracunculosis): Guinea Worm Eradication Program started all over the Sudan in 1993 by postal survey followed by active case search in all Northern states and accessible districts in the South (mainly capital cities). The national programme has been coordinating during the conflict period with OLS in the south. Case Containment strategy started in 1997 in the Northern states while the (OLS) in the south implemented case management strategy. Sudan harbors more than 80% of the global Guinea Worm case load. In 2005 about 5,000 cases were reported in the country, in 2442 endemic villages. No endogenous cases were reported from the north since 2004. State Prevalence Upper Nile 19.6 % East Equatoria 33.4% Bahr Eljebal 10.8 % Kassala 5.4 % Gadarif 4.8 % Sinnar 1% White Nile 3.3 % Blue Nile 27% South Kordofan 6.6 % Khartoum 4.5 % North Kordofan 41.0% Algazeera 26.0% 35 After signing of the CPA more cases were reported in the south mainly from the previously inaccessible areas. Currently the control activities in the south are carried out by the GOSS. 2.10.9 onchocerciasis There are about 2 million people at risk of developing onchocerciasis (river blindness) mainly in North Bbahr Algazal state and the Northern State. 2.10.10 Leprosy: Leprosy elimination programme was established in 1992. The programme managed to eliminate leprosy from all Northern state and the global target is reached in 1998, whereby the number of reported cases is less than one case per 10,000 of the population (0.6 case/10,000 in 2006). The number of discovered cases increased gradually from 260 cases in 1991 to a beak of 3,800 in 1995. The number of cases started to decease thereafter gradually to reach 625 in 2005. The total number of cases discovered since 1992 reached 31,407 cases. The number of treatment centres reduced from 720 to 280 centrs located where the cases are still reported. The treatment is provided free of charge (donation from GLARA, TLM and WHO). Completion of treatment has reached 96% and the disability associated with the disease (grade 2) has been reduced from 20% to less than10 % in 2005. In south Sudan the disease is still prevalent especially in states previously controlled by the SPLA, its exact magnitude and incidence need to be determined 54,890 49,471 41,493 20,299 7,266 5,041 0 10,000 20,000 30,000 40,000 50,000 60,000 70,000 2000 2001 2002 2003 2004 2005 N U M B E R O F C A S E S Leprosy (New reported cases 97-2005) 0 500 1000 1500 2000 2500 3000 3500 4000 19 91 19 93 19 95 19 97 19 99 20 01 20 03 20 05 36 2.11 Prevention and Control of Outbreaks Sudan is prone to a wide variety of epidemics including meningococcal meningitis, Viral Hemorrhagic Fevers and Acute Watery Diarrhea that keep causing recurrent outbreaks in different seasons and locations in the country. Acute Watery Diarrhea/Cholera for instance, starts to unfold over the last couple of years. There are various factors contributing to the vulnerability of Sudan to the risk of communicable diseases; • poor coverage of the country by the disease surveillance system, particularly in Southern Sudan; • low coping capacity of the health system; • poor access to health care and fragile health care systems in the country resulting from various conflicts, displacement settings and ongoing population movement internally and across the international borders; • impaired or lack of efficient environmental health system coupled with low-scaled civil services of water and sewage disposal. Meningococcal meningitis: The largest recent outbreak of meningococcal meningitis occurred in Sudan in 1999 with more than 33,664 cases and 2,508 deaths (CFR: 7.5%). It was followed by another large scale outbreak in 2006 with 6,487 cases including 475 deaths (CFR: 7.3%). Table 19: Reported CSM cases from 1999 to 2006 with attack rate and immunization coverage CFR Deaths Cumulative attack rate/100000 Cases Year 7.5% 2508 115 33664 1999 9.2% 468 17 5076 2000 14.9% 336 7 2252 2001 18.9% 455 8 2407 2002 ٪11 158 4 1436 2003 15.4% 175 3 1133 2004 ٪3.46 124 11 3703 2005 7.3% 475 19 6487 2006 Yellow fever: is endemic in some parts of Sudan where the vector is found. Between 1940 and 2005, 4 outbreaks occurred in the country with a total of 16,538 cases out of which 1,926 deaths have occurred, giving 11.7% overall CFR. Table 20: Yellow Fever Outbreaks in Sudan Year Area Cases Deaths CFR 1940 Nuba Mountains-South Kurdofan 15,633 1,627 10% 1959 Alfunj-Blue Nile 114 88 77% 2003 Imatong-East Equatoria 178 27 15% 2005 South Kurdofan 613 184 30% Acute Watery Diarrhea: one of the epidemiological events that deserve thorough researches and better understanding of the factors involved in the spread of the diseases. 37 Disease surveillance system: The existing disease surveillance system in the country is a sentinel based one where surveillance reports are sent by the state health authorities on weekly basis using a standard reporting format. However, during the period of an outbreak, daily reporting systems are established between the epidemiology department of the FMOH and the health authorities of the affected states. For some diseases, three types of surveillance systems are currently in use; • Sentinel surveillance system: currently there are over 650 sentinel sites sending weekly reports on 22 reportable selected diseases. These health events are reported on the basis of standard case definitions alone. Each sentinel site covers a geographic area of at least one administrative unit. • Early Warning and Alert Response Surveillance System (EWARS): in view of the humanitarian crises in Darfur, a surveillance system for monitoring morbidity and mortality amongst the internally displaced population was established to monitor transmission of epidemic prone diseases in the camps and settlements. The system was established jointly between FMOH, WHO, other United Nations agencies and NGOs. The main objective of this early warning and alert response surveillance system (EWARS) of epidemic prone diseases is to: • ensure timely detection, response and control of communicable diseases outbreaks in Darfur; and • monitor the trend of communicable disease transmission amongst the Internally Displaced Populations (IDPs) in Darfur in order to trigger appropriate public health interventions timely and promptly. • Laboratory based Surveillance: Meningococcal meningitis is the only disease enjoying this tool of monitoring. Sudan has, recently, been included in the WHO/EMRO's network for laboratory based bacterial meningitis, which is being implemented in six out of 25 states in the country. The laboratory based bacterial meningitis surveillance system was introduced in Khartoum state in 2004 and is now being expanded. 38 3 Challenges and opportunities 3.1 CHALLENGES Political environment: With the signing of the peace agreement, Sudan has about turned the corner in the way international assistance can be framed and delivered to address the critical constraints affecting the health sector. The political environment, although improving, remains delicately balanced. Urgently needed health interventions can be used to further improve the environment and build trust between the North and the South. Health should be used as "a bridge for peace". Increased coordination of the current efforts is needed to ensure that the relief activities are coupled with capacity building to make a smooth transition from response to recovery and development in areas of conflict. Commitment, both from the government side and the donors, is needed to ensure continuous support to recovery and development activities and to prevent the entry into a vicious circle of chronic emergency – acute emergency – chronic emergency. The governance function needs to be strengthened at all levels of the Health System. The FMOH has a relatively good capacity in terms of developing health polices and plans on all aspects of the Health System, guided by a National Health Policy. However, the ability of the FMOH to translate those polices into implementable programs at the state and local levels are still insufficient. The capacity of the FMOH is especially limited in the areas of health legislation and regulation, standard setting for public and private health facilities and academic institutions and building partnership with the non-state sector and civil society organizations. These are relatively new areas where the FMOH requires substantial technical assistance. In addition, the organizational and management capacity of the State Ministries of Health (SMOH) to provide effective health services is quite limited. For instance the management support systems are either poorly functioning or non-functional all together. Examples of these include the financial, personnel, and logistics management systems, as well as other support systems such as referral, monitoring and supervision, drug and contraceptive supply, and repair and maintenance. All these systems are essential for delivering effective health services. Institutional weakness: The health sector institutional capacity to respond to health needs and expectations is insufficient calling for immediate interventions and resources aiming at restoring and scaling up the PHC services, mainly in more deprived areas. Together with the lack of resources; the managerial capacity especially at the state level, is quite low for the decentralization model. The peace process has brought further challenges to the sector, increasing the demands on the weak decentralized system. In particular, the different levels of governance, which are envisaged in the power-sharing protocols, will require the allocation of responsibilities among the three layers, avoiding possible conflicts of competencies and ensuring harmonization of technical areas. Inadequate financing of health sector: The health system in Sudan is under funded with a total PHE estimation of 36 US $ per capita. The government share in the total health expenditure is around 30%. Reliable data is not available on financing and spending by households, private spending in addition to costing. It is estimated that out-of-pocket expenditure exceeds 65% of the total health expenditure, which is inequitable. Further, there is limited social protection; only 15% of the population are covered by prepaid schemes in spite of the fact that there is high level of poverty. In 2005, the budgeted central health spending was around 1.5 of the GDP which represents 5.1 % of the total government budget amounting to US$ 9 per capita The information system (HMIS): is inadequate for informing the decision making process on priorities for resource allocation and for monitoring trends in health needs and programs. The HMIS needs revision and redesigning to make it broad based including information pertaining to 39 community, private sector and vertical programs and also responsive enough to provide specific information required for monitoring, planning and programme improvement.. The emergency information system needs to be established and strengthened to aid in early warning, information sharing among partners, evidence-based decision making, as well as research and documentation to add to the institutional memory of the ministry of health. Inequities in the health system: Despite gaps in information on distributional data, there is anecdotal evidence that years of war and conflict have created serious inequities in the financing as well as the provision of health care in the Sudan. The inequities are not only between the states of the north and the south but also within the various states. Gaps in human resources for health: There is a huge gap in the human resources, exceeding 64,000 nurses, medical assistants, pharmacy technicians, laboratory technicians, environmental hygienist, and anesthesia technicians. As a result of peace and relative stability, some health workers are expected to return, especially those working in refugee camps in neighboring countries. In addition, the quality and performance of the present work force is inadequate calling for systematic continuing professional development. The Health Professional Councils need to be strengthened to undertake their responsibilities in setting professional standards, enforcement of these standards, regulation of the workforce, and accreditation of education and training facilities in collaboration with other stakeholders. 3.2 OPPORTUNITIES The peace agreement has brought forth strong prospects in relation to the shared vision, strategic objectives, and operational implications for the realization of a peaceful and unified Sudan, thus facilitating access to all areas of the country, ensuring the security of personnel, and beginning the implementation of rehabilitation, reconstruction and development. Peace will free resources, previously devoted to war, to support social services. A large number of Sudanese expatriates are expected to return and add to the existing human resources. Rapid economic growth and political commitment; due to increasing oil revenues and growth in different sectors of the economy, the economy of the country has witnessed stable and sustained growth over the last 5 years. The annual GDP growth rate has been around 7% ranking the country as one of the fasted growing economy in Africa and expected to continue with the same pace over the coming years. The GDP has increased from US$ 330 in 2000 to above US$ 700 in 2006 and expected to reach 2000 by 2011. The central Government is planning a gradual increase on health spending to 1.5% according to the Mid-term expenditure framework. Human Resource for Health: The availability of health training institutes in the Sudan, compared to other similar countries, is considered a great opportunity for the provision of highly qualified human resources. Moreover, the FMOH is taking the primary responsibility for planning, monitoring and evaluating the health workforce in order to meet the health needs of the country on setting the minimum acceptable educational standards and performance levels required to be attained in health professional training courses. The FMOH, recognizing the varied and inadequate levels of training of health workers, is committed to ensure that all training of health workers is relevant, cost-effective, of acceptable standard, competency based and addressing the priority health needs of the Sudan. Federalism and Decentralization policy has an overall objective of minimizing disparities that are quite significant between federal, and states, urban and rural areas, and war affected and more stable areas. The local health system, based on the district health model, will be considered the building block of the national health system based on the PHC approach. Health affairs shall be accommodated within the local government authority that will emphasize transparency and accountability to the state authorities and their community. While it is anticipated that responsible and culturally sensitive decentralization in Sudan might lead to more 40 equitable, accessible, acceptable quality of health services at the local level, more efforts need to be taken to validate appropriate application and benefits to the communities served. Enhanced international commitment to support the health system in Sudan is strong as reflected in the wide presence of multiple donors and organizations, especially WHO, other UN agencies and NGOs and in pledges of support by governments. Clear commitments and monitoring indicators will be supported by strong domestic ownership and resources mobilization. FMOH is scaling up its efforts to take the leading role in effectively coordinating different development organizations, donor agencies, NGOs and also other government departments to ensure an efficient and optimal utilization of resources. Solidarity and patriotism: the Sudanese communities are well known by their strong national commitment, values of social solidarity and culture of tolerance and diversity. This will add up to what has already been legally addressed in the CPA especially power and wealth sharing across different regions of the Sudan. 41 4 Guiding polices and long term strategies: 4.1 The 25 year Strategy This strategy was produced in response to the national government initiative of developing a 25 year strategic plan for all sectors in Sudan. The major priortites were to embark on an effective health system reform based on fair financing options, reduce the burden of diseases, promote healthy life styles, develop and retain human resources and introduce advanced technology while assuring equity, quality and accessibility. The strategic directions for the coming 25 years stressed that improved health indicators for all citizens will be achieved through a broadened primary health care concept. Attention will be given to human resources development through well planned and managed programmes. Emphasis will be on health financing and pro-poor system reforms aiming to increase allocations and investing on health and especially targeting the poor and the disdvantaged groups. Health services and goods with public health importance will be the responsibility of the government. 4.2 The National Health Policy, 2006 The national health policy draft document summarized the policy directions for the health sector for the coming periods. it form a road map for the health sector-wide development and its national strategic directions for many years to come. the general guiding policies are summarized in paragraph '' 1.4 General Guiding Principles for the Health strategy'' page 3 of this document. 4.3 Health Policy South Sudan (1998) A health policy for southern Sudan came into effect on October 1, 1998. The policy emphasizes health as a central development issue. The main features of the policy are as follows: The primary health care system will be backed by an appropriate referral system and integrated with disease-specific programs. Emphasis will be on health promotion and prevention of diseases as well as proper use and control of drugs. Communities will be mobilized to play a major role in all aspects of health services. They will be expected gradually to shoulder an increasing share of the costs and hence reduce their dependence on external sources. Human resource development will include reorientation of old and new health workers and communities in the concept of primary health care. Services that have a predominantly public effect or deal with vulnerable sections of the population shall be provided free of direct charge. An update version of the policy was done in 2006 and a draft is ready for approval. 4.4 Joint Assessment Mission Framework 2006-11 (JAM) This report has been prepared by a joint mission represented by the Government of Sudan, SPLM, World Bank, UNICEF, WHO and UNESCO. The purpose of this report was to assess the current situation of basic Social Services including health based on the available knowledge and information. The JAM report contains situation analysis and key recommendations for development of social services in Northern and Southern Sudan. The quantum of inputs is 42 different between the Northern states and Southern states of Sudan but priorities are almost similar as mentioned below: Healthcare financing: with the aim of substantially increasing public spending and reducing regional inequalities by targeting the more deprived regions. Cost recovery as a source of financing will be reconsidered. A substantial effort will be placed in strengthening financial management at the central and state levels through technical assistance and training. Of special consideration will be the provision of free health care services for children under the age of 5 years. Technical assistance and capacity building: Priority areas are policy development, planning/regulation/supervision, financial management, human resources strategies, pharmaceutical policy and regulation, and health information systems. In particular, support is needed for strengthening decentralization through the transfer of financial, administrative, and political authorities to the states and local levels. Investment in infrastructure: as per the stated targets to increase coverage, focusing on disadvantaged areas. It will mostly consist of rehabilitation, and focus on the most deprived areas. Investment in human resources: This component focuses on skilled Primary Healthcare (PHC) workers. The recovery programme should provide incentives for most PHC training programmes, graduates to be posted in areas of need, re-allocation of a number of existing staff, and for an intense programme of in-service training. Expanding service delivery & quick wins: involve significantly increasing funding for recurrent costs and small-scale rehabilitation and re-equipping of the health system in the underserved areas. It also needs to involve strengthened partnership with international and national NGOs in order to expand services, targeting under-served areas. Priority health services to be strengthened are those addressing the main causes of child and maternal morbidity and mortality, including skilled birth attendants, referral services, expansion of family planning programmes, provision of reproductive health commodities (contraceptives, delivery kits); prevention, treatment and counseling services for STIs and HIV/AIDS, and prevention of harmful practices, including Female Genital Mutilation (FGM). Accelerated Child Survival Initiative Recent analysis of the progress towards the achievement of the MDG indicate that many Sub Saharan African Countries are not on track to reach the MDG. Although Sudan belongs to the Middle East and North African Region (of UNICEF), the country’s indicators especially MDGs 4 & 5 are lagging behind those of other counties in MENAR. Some of the reasons have been highlighted in the foregoing. Yet, it is well known that the interventions to reduce child mortality by two-thirds are available, the question is how to bring them to scale and to ensure that they reach those who need them most. To assist African Countries to accelerate the achievement of MDGs 4and 5, support is being provided by UNICEF, WHO, World Bank and other partners to scale up the provision of key high impact low cost interventions through well planned delivery strategies. Sudan will take full advantage of this initiative which will enable the country to expedite the fulfillment of achieving the MDGs 4&5. As highlighted already, most of the proposed interventions are already ongoing and will only require re-packing and going to scale. In Sudan, the implementation package will eventually include: A minimum package(high-impact, low-cost interventions that need to be implemented at scale immediately ( e.g. ITNs for pregnant women and infants; ANC, PNC; EBF; neonatal care; EPI; vitamin A supplementation; deworming; IMCI, PMTCT, BEmoC; antiretroviral drugs (ARVs) for the management of paediatric AIDS; and Hib vaccine for haemophilus influenza type B; an expanded package: 43 equivalent to the minimum package plus extra evidence-based interventions that include additional neonatal care and comprehensive emergency obstetric care and a maximum package(expanded package plus new planned interventions such as pneumococcal vaccine, and intermittent preventive treatment of malaria in young children and expanding the provision and availability comprehensive EmOC. It is expected that a 3-phased approach will be use: i.e. (a) a Jump-start’ through a national level campaign that aims to reach every child in Sudan with a few key critical interventions through the EPI infrastructure. At the minimum, this should include measles vaccination, provision of LLITN, Vitamin A supplementation and deworming for under-five children and TT immunization for Women of Child Bearing Age (WCBA). There will be ongoing parallel intervention of community capacity building for family/community level care as well as support to improved delivery of routine family/community interventions in selected localities/ communities to start with (b) Pulse Activities with key interventions to be supported at the sub-national level with the following components: (i) mapping to identify low coverage areas and and provide specific key interventions (every three -6 months); (iii) building capacity at all levels for scale up at locality and community levels for microplanning, monitoring including facilitating the establishment of community development committees and upgrading the skills and numbers of community health/nutrition promoters to increase demand for services(c) the third phase is the scaling up of family/community activities to ensure that all Sudanese children have access to the defined minimum package of care, no matter where they live or work. 44 5 Strategic framework: In the last decade progress towards achieving the MDGs in Sudan has not been very significant; some indicators have actually deteriorated. Many constraints have been behind this slow progress or deterioration, in addition to the health system weakness, these include, inter alias, the civil strive in the South and other parts in the county, and the low levels of spending on health that make the significant part of the system (the PHC levels) not responding to the needs. Two important milestones have occurred recently and have created favorable conditions. These include the improving macroeconomics framework reflected in the significant and the steadily increasing economic growth rate. The GDP has achieved an average of about 7% annual growth rate over the last 5 years and expected to sustain the same pace over the coming period (the GDP has increased from 330 in the 90s and early 2000 to around 700 in 2006)25 . The second important change is the signing of the Comprehensive Peace Agreement (CPA). However, many challenges are still ahead and needs to be well addressed to bring about the desired changes in the health outlook. These include how the health system is organized; how services are delivered and how to finance /pay for health services. 1) Addressing the how the health system is organized: encompasses strengthening the stewardship function of the MOH. This will address the following: Generation of intelligence for more informed decisions and better health outcomes, formulating strategic policy direction, ensuring tools for implementation of policies and interventions such as powers, incentives and sanctions, building partnerships for health, ensuring a fit between policy objectives and organizational structure and culture and ensuring accountability. The focus will be on building the capacities of the Federal and State Ministries of health and local health authorities. The strategy will further the implementation of the recent reform initiative implemented by the FMOH, the local health system. Organizational redesign aiming at improving the leadership role of the FMOH, good governance and accountability are the core of the interventions and policy directions envisioned. 2) How services are delivered: the strategy will strengthen and revitalize the PHC, since primary health care services substantially affect the health outcomes of a population because they tackle diseases that constitute most of country's burden of disease. Linking the health facilities through networking will be addressed. Also the strategy emphasizes availing the needed staff and competencies, improving the staff skills, ensuring sustained and adequate supply of drugs and other consumables, revamp the basic equipments and technology used. The vital role of the private sector will be acknowledged and needed guidelines for Public-private partnership and contracting will be developed and enforced. Improving the performance and quality of care in secondary and tertiary referral levels will receive the needed attention. Appropriate strategies to implement the ACSI will be developed and implemented. 3) Financing and paying for health service: the sun functions of health include collecting revenues, pooling resources, and purchasing services. They should be geared to improve health outcomes. The strategy aims at increasing investment in health while addressing the needs of the poor, provide financial protection, and ensure consumer satisfaction—in an equitable, efficient, and financially sustainable manner. The 25 Sudan has moved from countries with low Human development index in the 1990s to Medium Human Development Index in the 2002 onward (HDI was 0.428 in 1990 and 0.512 in 2003) 45 expansion of prepaid schemes and health insurance to achieve universal coverage is a key priority and vision to be realized in the life span of this strategy These should be part of a comprehensive and splendidly designed reform initiative package. The main objectives behind this reform are to improve the health system performance, making it sustainable, equitable, affordable and responsive. This 5 year strategy, being built on what have been achieved in the past, draw lessons from previous pitfalls, and benefit from the growing international knowledge stock, experience, and innovative thinking in the social and health arena. Further, being part of a comprehensive framework stipulated in the National Health Policy (NHP), the 5 year strategy aims at fostering the future evolution and development of the health system. In line with African Union initiative, a Road map for the achievement of the ACSI will be included in key strategic and policy document and be implemented by the government with the support of partners. 46 6 VISION FOR HEALTH To build a healthy nation, with emphasis on the health needs of the poor, underserved, disadvantaged and vulnerable populations, thereby contributing to the achievement of the Millennium Development Goals and the overall social and economic development of the country. 7 MISSION STATEMENT The Ministry of health is focusing on the provision of equitable and quality health services that meet the Sudanese people expectations and needs, promote their health, improve their quality of life, and permits them to lead a dignified and prosperous life. This will be done through putting health at the centre of the country development policy, using best available evidence and efficient utilization of resources. 8 Goals, Strategic Objectives, Targets and Indicators The vision for the health sector, set forth by the FMoH 25-year Strategy is to fulfill the MDGs, contribute to poverty reduction, and improves equity across and within states, and among vulnerable groups. The targets and indicators to be achieved by the country including the Millennium Development Goals related to health are summarized as follows: Goal 1 - Improve governance of the health system Strategic objective 1 - Strengthening the governance and institutional capacity of the decentralized health system at all levels Targets - Strengthen the institutional capacity of the FMOH in policy development, management, planning and implementation Improve leadership and governance function of the FMOH particularly in health legislation, standards setting and coordination; Reorganize and strengthen the decentralized health system structures, systems and capacities at SMOHs and local health authorities Indicators - # of policies developed and implemented by the FMOH /SMOH /LHA # of management sub-systems developed and implemented by the FMOH /SMOH /LHA # of staff at FMOH/SMOH/LHA trained and currently working in the areas of management and leadership. # of sub-national health councils/administrative units established and functioning Strategic objective 2 - promote the culture of research and provide evidence for policy and decision making. Targets - Develop the national research priority agenda Dedicate at least 2% of the health budget to conduct priority researches Build a critical mass of health researchers 47 Make health research findings accessible and available Assure compliance to research ethics Indicators - % of budget allocated for health researches Number of health professionals conducted/ participated in health research Availability of up- to- date local health research database Number of professionals trained evidence based policy/decision making/practice Number of health research council meetings Number of functioning ethic review committees Goal 2 - Improve coverage and accessibility to quality health services Strategic objective 3 - Ensure equitable coverage and accessibility to the essential PHC package Targets - Increase coverage with PHC health facilities from 1/14,000 population to 1/11,000 population Improve the delivery of the PHC essential package in the existing health facilities from 22% to 63% Increase access to community/family level health services through strengthening community development committees; building the capacity and remuneration of community level workers; provision of appropriate supplies, support to monitoring Indicators - Percent of population with adequate access to essential PHC services (living within 5 Kilometers of a PHC facility). Health facility- population ratio % of primary health facilities providing quality basic health care package % of the targeted communities with community level development committees; % of community health workers employed, trained to provide family/community health services and % remunerated. Strategic objective 4 - Ensure adequate production, equitable distribution and retention of skilled human health personnel based on the health system needs. Targets - Increasing the training capacity of the allied health Academy and its branches in the states by 120% (from 3,090 to 7,000). Production of 22,500 nurses 5,000 MAs/technicians and 7,500 midwives Enroll 3,000 doctors locally and 750 abroad in general medical specialties Enroll 550 doctors abroad and 15 locally in sub-specialties Enroll 250 and 125 nurses/Allied health personnel locally and abroad for post basic degrees respectively Indicators - % increase in training capacity for each category of allied health personnel 48 Number produced of each category of health personnel Strategic objective 5 - Ensure equitable coverage and accessibility to quality referral secondary and tertiary health care services at all levels of health care Targets - Ensure 50% of district hospitals are providing at least one of the basic specialties (Internal Medicine, Pediatrics, Obse.& gyne. and general surgery) Ensure all district hospitals are providing emergency services and essential diagnostic services. Ensure all states' hospitals are providing basic specialties (Internal Medicine, Pediatrics, Obse &gyne and general surgery) and priority sub specialties and related referral diagnostic services. Reform major federal hospitals aiming at bridging the gap in tertiary services and establishing autonomous sub-specialized centers of excellence (see annex 2) Establish efficient and effective referral system and ambulance network at the state level. Expand triage system to cover all federal, state and district hospitals. Indicators - No of district/state hospitals providing basic/priority specialty services No of states with functioning referral/ central ambulance systems % increase in availability of sub-specialty services % of hospitals implementing triage system Strategic objective 6 - Reform and develop a pro poor health care financing policies Targets - Increase public spending on health to 7% of the total central government budget (2.5 % of the GDP). Increase the intra-sectoral allocation of government health spending on primary and first-referral services to 50%. Develop and implement interventions (subsidies and prepayment schemes) to substantially reduce financial barriers specially for service package targeting mothers and children Indicators - Public central health expenditure as a percentage of national budget Public health expenditure as a percentage of GDP % of the PHE out of the THE Per capita health expenditure (in international dollars PPP) % increase of spending on PHC services % decrease in direct out of pocket expenditure/ service Strategic objective 7 To improve the availability to affordable, safe and effective essential medicines Targets - Assure the maintenance of quality and safety of all medicines through out the supply chain 49 Increase access to medicines by 80% in public health facilities Promote rational use of essential medicines in public facilities Indicators - % of states implementing post marketing surveillance programme % of population with access to medicines Number of states with a functioning revolving drug fund system % of contribution of local drug manufacturers % reduction in adverse drug reactions Strategic objective 8 Introduction and adoption of quality management systems in all health facilities Targets - Establish quality improvement programmes in all tertiary care centres, 50% of secondary care hospitals and 10% of PHC units. Establish patient safety programmes in all tertiary and secondary care hospitals Establish infection control programmes in all tertiary and secondary care hospitals Enroll at least 80% of tertiary and secondary care hospitals and 20% of private hospitals in a voluntary accreditation programme Recruit at least one professional quality manager at each state. Indicators - % of health facilities running. quality improvement programmes % of health facilities running infection control programmes % of health facilities running patient safety programmes Adverse events/Hospital infection rate %/Number of hospitals (public/private) joined/ accredited by the accreditation programme Goal 3 - Improve child health Strategic objective 9 - Reduce child morbidity and morality Targets - Reduce under-five mortality rate to 70 per 1,000 live births by 2011 (compared to the estimated average of 122 in 2006) At least 90% of children > 5 years nationwide receive an integrated package of interventions (measles vaccination, LLITN, deworming, Vitamin A) provided through the EPI infrastructure as part of the Accelerated Child Survival Initiative. Reduce malnutrition among under-five children by at least 30% of 2006 level. Attain 85% national coverage with DPT3, HepB3 & Hib3 with at least 80% coverage in each Locality. Maintain the country polio-free. Achieve measles elimination by the end of 2010. Achieve neonatal tetanus elimination by the end of 2010 (<1 case per 1,000 live births). Attain 90% coverage of children under 5 years of age with Vitamin A supplementation. Indicators - Under-five mortality rate 50 Infant mortality rate No and % of primary HC facilities providing quality IMCI, Nutrition, and EPI services Prevalence of under-weight, stunting and wasting under five years of age Proportion of 1-year-old children immunized against measles Proportion of 1-year-old children immunized with DPT3 % of localities with DPT3 & HepB3 coverage of at least 80% No of confirmed wild polio cases % reduction in measles cases/100,000 population No of localities reporting < 1 case of neonatal tetanus/1000 live births % of children under 5 who received at least two doses of Vit. A annually. Goal 4 - Improve Maternal Health Strategic objective 10 - Reduce maternal and neonatal mortality and morbidity Targets - Reduce maternal mortality to 260 per 100,000 live births by the end of 2011 Reduce neonatal mortality to 20 per 1000 live births Increase institutional delivery from 14 % to 25% Increase postnatal care to 40% Ensure that 70% of referred maternal cases have timely and quality EmOC services Reduce major obstetric morbidities especially Vasico-vaginal Fistula (VVF) and provide needed health care for those affected Increase villages (> 1000 population) covered by skilled personnel to 90%. Increase percent of Service Delivery Points (SDP) providing more than 3 FP methods to 90% Increase percent of Service Delivery Points (SDP) providing ANC from 16% to 90% Strengthen communities involvement to support maternal and neonatal health (MNH) and overcome harmful traditional practices at least in the catchment's areas of health facilities providing midwifery services Strengthen and sustain the knowledge and capacity of youth (Secondary Schools graduates) in understanding MNH needs and risks Indicators - Maternal Mortality Ratio Neonatal Mortality Rate Proportion of births attended by skilled health personnel % of pregnant women who received prenatal and postnatal care % of referral facilities providing quality EmOC. % of institutional deliveries C/S rate % of SDP providing ANC/FP CPR 51 Percent of villages (> 1000 population) covered with SBA Percent of FGM Goal 5 - Combat HIV/AIDS, TB, Malaria, and other communicable diseases Strategic objective 11 - Ensure early preparedness and response to emergencies and epidemics Targets - Build the institutional capacity of the health systems for effective emergences and epidemic preparedness and response (guidelines, training of teams, buffer stocks, logistic support, risk mapping, contingency planning and rehearsals and Emergency information system) Promptly detect and abort within the acceptable standards > 90% of emergencies and epidemics Strengthen/ establish Comprehensive Integrated Surveillance and Response System Indicators - % of states/ localities with a functioning units for emergency/epidemics preparedness and response No. of emergency/ epidemics detected and aborted within the accepted standards No / % of health facilities that submit regular reports Strategic objective 12 - Reduce HIV/AIDS transmission Targets - Maintain the level of HIV/AIDS prevalence at less than 2% among the general population Increase awareness and knowledge about HIVAIDS from 11 to 70 percent by 2011 Increase percentage of health facilities providing syndromic management of sexually transmitted infections from less than 25% to 70% Ensure 100% safe blood transfusion in all health facilities Scale up of equitably distributed PMTCT services from 5 sites to 45 sites Increase the number of equitably distributed VCT centers from 45 centers to more than 270. Increase the number of patients on AIDS treatment including ARVs and OIs from less than 1000 to 20,000 by the end of 2011 Apply second generation surveillance including improved AIDS Cases reporting, behavioral surveillance and sentinel surveillance Build the capacity of the different partners including State AIDS program for effective and efficient program implementation Mobilize stakeholders and communities through activation of National and State AIDS Multisectoral Council Provide sustainable BCC and advocacy programs including different partners to ensure involvement of policymakers, communities, family and individuals in the AIDS prevention and to 52 Support people living with AIDS including combating stigma and discrimination Indicators - HIV prevalence among pregnant women attending ANC clinics Number of children orphaned by HIV/AIDS Percentage of women and men aged 15 – 49 who both correctly identify ways of preventing the transmission of HIV and who reject major misconceptions of about HIV/AIDS (By rural and urban) Number of people among most-at-risk target populations reached through BCC/counseling session(s) (By target population) Number of women and men with sexually transmitted infections at health care facilities who are appropriately diagnosed, treated and counseled Number of clients (By age & sex) received HIV test results and post test counseling Number of blood banks (public & private) providing HIV blood screening services using standardized protocols (By existing & new established) Number of people (By sex, age, pregnant women & children, new & follow-up) with advanced HIV infection receiving antiretroviral combination therapy Number of government sector(s) and private sector with a functional HIV/AIDS unit and has strategic plan with a budget for HIV/AIDS Amount of external funds disbursed and utilized by all the other partners for the HIV/AIDS programmes and activities (Disaggregated by disbursed & utilized in US Dollars Strategic objective 13 • Reduce Malaria related morbidity and mortality Target - Reduce the morbidity and mortality of malaria by 50 % (of 2000 figures) Avail access to effective treatment (according to the new national treatment guidelines) for 90% of population living in high risk areas Ensure that 80% of pregnant mothers and children < 5 years of age in high transmission areas have access to and use effective preventive measures including ownership of LLITNs (80%), IPT (80%) in pregnancy and other vector control measures targeted at the general population (e.g. larviciding) Promptly detect and abort within two weeks > 90% of malaria epidemics Improve quality of laboratory diagnosis of malaria in > 90% of health facilities with microscopy and deploy RDTs in >90% of dispensaries in all states with low/moderate malaria transmission Provide early diagnosis and treatment with ACT to 1.8 million malaria patients in remote rural areas with poor access to health facilities, through HMM strategies Progressively provide access to rectal Artesunate in 682 dispensaries in the 10 states with the higher malaria burden Upgrade the RBM capacity at federal and state levels 53 Indicators - Prevalence and death rates due to malaria Proportion of malaria risk areas using effective malaria prevention and treatment measures % of population in high risk areas who have access to effective anti-malarial treatment according to the National Treatment Protocol % of health facilities' laboratories with improved malaria microscopy/ availability of rapid diagnostic tests RDTs. % of states with a well functioning Malaria control Department % of pregnant mothers and children < 5 years of age in high transmission areas who have access to and use effective preventive measures Strategic objective 14 - Reduce Tuberculosis related morbidity and mortality Targets - Reduce the incidence and death rate from tuberculosis by 50% Detect at least 70% of estimated new infectious TB cases. Cure at least 85% of the detected infectious TB cases Indicators - Incidence (annual risk of infection) of tuberculosis per 100,000 people Proportion of TB cases detected Proportion of TB cases cured under directly observed treatment short-course Strategic objective 15 - Reduce Schistosomiasis related morbidity and mortality Targets - Reduce the prevalence of Schistosomiasis to less than 10% in all endemic localities Indicators - Schistosomiasis prevalence among the school children Strategic objective 16 Control /Eradicate / Eliminate other communicable diseases Targets - Reduce the no. of new leishmania cases by 30% in endemic states Eradicate guinea worm by 2009 Elimination of lymphatic Filariasis by 2015 Elimination of leprosy by 2011 Indicators - No of new leishmania cases detected and treated No of new guinea worm cases detected and contained No of localities with less than 1% prevalence of lymphatic Filariasis No of localities with less than one leprosy case/10,000 population Goal 6 to promote healthy life styles reduce the burden of non communicable diseases Strategic Objective 17 To reduce morbidity and mortality related to major non communicable diseases Target s - To increase early detection of targeted non-communicable 54 diseases (CVD, hypertension, diabetes mellitus, cancer, accidents and injuries) by 30%. To raise community awareness towards healthy life styles by 30%, and promotes behaviour & practice change by 30%. Support policies addressing the health needs of special groups (adolescence , elderly ), special settings(school health, health promotion workplace) and mental health Indicators - Prevalence of non communicable diseases Prevalence of Tobacco, snuffing and alcohol use Number of schools enrolled in school health programme Number of rules and legislations endorsed Goal 7 - Creation of an environment conducive to partnership building and promotion of the role the private sector Strategic objective 18 - Encourage private sector (for profit & not for profit) in contributing in health care provision and promote its collaboration with the public sectors Targets - Increase the complementary contribution of the private sector in care provision, Promote public private partnership Indicators - % contribution of the private sector in specific services Strategic objectives 19 - Support development of environmental health and community-based approaches for achieving health goals in partnership with other sectors Targets - Support policies and develop strategies and services that ensure all people have access to save water supply and effective sanitation Reduce adverse health effects of environmental hazards Develop and implement systems to ensure food safety, chemical safety, solid waste and industrial waste management Work in partnership with related sectors to combat pollution and control communicable disease vectors Indicators - No of developed policy/ strategy/ legislations No of active coordination councils/bodies 55 9 Strategies and key interventions 10 Priority strategic interventions Goal 1: Improve governance of the health system Strategic objectives 1: Strengthening the governance and institutional capacity of the decentralized health system at all levels a) Institutional strengthening and improved governance in the FMOH This component shall be put into operation based on the following implementation strategies: • Institutionalized health policy formulation process: For this purpose the policy unit in the General Directorate of Health Planning and Development, Ministry of Health should be strengthened. This unit should provide support in health sector policy formulation and analysis and oversee the policy implementation and its impact in federal, states and localities. This unit should be comprised of well qualified and experienced professionals having diversified competences and knowledge. • There is a need to review the organizational structure of FMOH/ SMOH/ HAs and reorganize it with explicitly defined roles of each level and functional unit. Job descriptions have recently been updated by the Ministry of Health, however, there is a need to further refine the job descriptions and make some arrangements to ensure performance of the staff according to their predefined job descriptions. • Training and capacity development – short- and long-term training shall be provided to FMOH staff in key areas such as leadership; health system development; governance, planning, equity and health; health financing and health economics; human resource development; organization and management; use of information for informed decisions; and project management. • Strengthening governance – The governance function shall be strengthened through developing the FMOH capacity in health legislation and regulation, standard setting for public and private facilities and institutions, partnership building with the non-state sector and civil society organizations and improved accountability. In addition, the FMOH should adapt and take responsibility for the essential public health functions26 in its national policy. These are relatively new areas for which substantial technical assistance shall be required. • Policy and systems research – This shall be achieved through strengthening of research unit in the Directorate General of Health of Planning and Development, FMOH. Targeted policy and systems research shall be outsourced and facilitated by the Unit to provide evidence for developing national and sub-national health policies. Research priorities shall be identified based on consensus among all stakeholders in the health arena. Potential areas for research include the feasibility of contracting-out health services; roles of the private sector and public private partnership; health financing and utilization issues including equity in the financing and provision of health services; mapping of physical and human resources in health; and social determinants of health. • Management systems development –capacity development at the institutional level through the development and strengthening of existing management systems in the FMOH. These included but not limited to, systems such as financial management, 26 See Essential Public Health Functions, PAHO/AMRO (2004). 56 personnel management, drug management, procurement and logistics, monitoring and supervision; health information management. • Health management information, Monitoring and Evaluation System: Establishing effective, efficient and sustainable Health Management Information and monitoring and evaluation system that provide valid, timely and reliable data is an important element in the improvement of health system performance. Such system if better designed and geared to this aim can provide and create demand for using data to inform decisions aiming at improving the health outcomes of the population. • Health Information System shall be reviewed and redesigned to make it broad based including information pertaining to community, private sector and vertical programs. • The health Financing Policy needs to be revised to be in accordance with the provision of the National Interim Constitution. There should be a clear financing policy with resource allocation formula to the different levels of the government levels. Federal Ministry of Health in coordination with the Ministry of Finance and National Economy should evolve a financial policy to ensure continuous increase in resources invested in health, focus on supporting lower level services in underserved areas, develop a transparent and equitable resource allocation formula and enhance financial allocations to the states for successful implementation of the decentralized system. Establishing National Health Accounts System for better management of financial resources is an important element for monitoring the financial system. • Technical assistance- The above components shall be implemented with the support of targeted technical assistance in the form of short- and long terms experts who shall provide institutional support in the areas of governance, health legislation and regulation, system development, policy analysis and research, and information technology support for updating management systems in the FMOH. • Physical infrastructure and equipment- infrastructure support shall be provided at the level of the FMOH. Priority area for support shall include information technology including computers and accessories, vehicles, renovation and construction/rehabilitation of administrative offices. b) Strengthening and reorganization of the SMOHs and local health directorates in a decentralized health system The health sector has to build its structures at all levels following the decentralization process going on in the country. Implementation will be based on the Local health system reform model adopted by the FMOH. The implementation plan will start by pilot in 6 localities to be followed by expansion phase. The implementation will be carried out in partnership with local communities, federal directorates (planning, state affair, and training directorates), FMOH programs (PHC programs, Malaria, Leishmaniasis, Schistosomiasis and environmental health program), States and localities authorities, NGOs; UN group, national and other international NGOs working in the field of health and development. Main activities would include; • Training and capacity development – Multiple short- and long-term training shall be provided to SMOH and Local Health Authorities staff in key areas such as strategic and operational planning; personnel, financial and logistic management, system development, monitoring and supervision, community mobilization and participation, and training and upgrading skills of health workers in primary health care especially at the locality level. A critical group to be targeted in addition to the state and local authority's managers are the managers of state and rural hospitals. 57 • Good governance and systems development – Governance in health shall be improved through the development and strengthening of management systems in the SMOH and local health authorities. In addition to development of the financial, personnel, and logistics management systems, key support systems shall include referral (especially emergency obstetric referral system), monitoring and supervision, drug and medical supplies, and repair and maintenance. • Systems and operational research – The focus shall be on operational aspects of the health system, which shall be undertaken based on the priorities identified by the Health System Research Unit in the FMOH. Potential areas for research include in depth health system analysis, referral system development, staff motivation and absenteeism, revolving drug fund, public-private partnership and community based initiatives. • Technical assistance - The above components shall be implemented with the support of targeted technical assistance in the form of short- and long term experts to provide hands on support in the areas identified above. Technical assistance shall include, among others, training and capacity development, policy advice, development of tools, manuals, guidelines and protocols. • Redeployment and recruitment of staff – This shall be undertaken to reduce the imbalance in the availability of staff between the federal and state levels, as well as, within states. In certain state MOH and local health authorities, special incentives shall be provided to recruit staff on a contractual basis in order to develop the necessary capacities to organize, manage and deliver health services. • Physical infrastructure and equipment – Based on an adequate needs assessment infrastructure support shall be provided to all the SMOHs and local health authorities. Priority area for support shall include renovation and construction of administrative offices, supply of computers and accessories, office furniture and vehicles. Strategic objective 2: promote the culture of research and provide evidence for policy and decision making. The interventions will target the following: • Create a framework for leadership: The research Directorate is the executive body for the National Research council. This council is formed to act as a country mechanism for governing of health research. It includes stakeholders. It plans and monitor implementation of the National Research Policy and plans through periodic meetings. The research Directorate will be strengthened and a program for leadership will be developed. • Development of the national priority agenda: in order to focus research resources and energies, areas that are critical to the health and well being of the population will be defined in collaboration with stakeholders. The health research community should move over time to focus their health research activities in these areas. Criteria will be applied to ensure funds are consistent with research priorities. Funds will be aligned for programmes and researches of the outlined priorities. • Establish institutional technical and ethical review committees at Federal and states institutes: The National Technical and Ethical Committees are responsible for setting the national regulations and guidelines and endorse selected research projects of national significance. All states ministries of health, universities, research centres and other institutes will be encouraged to form their review committees' inline with the national rules and guidelines. The Research Directorate will build the technical and ethical capacities through training workshops. 58 • Strengthen partnership: The Research Directorate will facilitate collaboration between key stakeholders through different forums and networking. The research must reflect the appropriate balance in health research activities in biomedical, clinical, health service delivery and population health areas. Joint projects, involvement in different steps and exchange of results through internal and external partnership will be encouraged. • Increase the number of active health researchers: it is essential to attract, train and retain health researchers and health research trainees and health professionals to work in research. A comprehensive research career path program including rewarding opportunities will be implemented. Grant funding to help junior researchers will be organized. Capacity building includes development of the supportive environment of adequate and appropriate space and equipment. • Work with partners in all sectors to create a permanent and stable research funding source: The National Research Council will work to ensure that 2% of programmes budgets goes for research and research related activities. The pool of health research funding will be increased by identifying and accessing other funding sources nationally and internationally. Benefit from the existing fund must be maximized through appropriate and transparent use. • Build the capacity of government and health professionals to incorporate available and new health research into appropriate interventions: This is to ensure knowledge transfer in order to apply what we learn. It is essential to ensure that all research projects include a knowledge transfer component. Beneficiaries should be given the opportunity to receive or access training and education regarding the benefit and methods of sharing and using information • Make health research findings accessible and available: all health care providers, health policy makers, the general public, commercial enterprises, and researchers should have access to research results. Strategies are to develop databases, encourage publications, and enhance public access to health journals and media sources. Goal 2: Improve coverage and accessibility to quality health services Strategic objective 3: Ensure equitable coverage and accessibility to the essential PHC package Expanding coverage and geographic access to quality basic package of PHC services. This five year strategy envisages different modalities for improving coverage and accessibility to the essential PHC package; this would include the following strategies; i) Thorough and rigorous mapping of available health facilities to rationalize investing on health infrastructure. Advance technology will be used to map these facilities and build a computerized database. Cost-effective, best quality, durable and cultural acceptable facility Models will be developed, to be used in the health infrastructure development plan, ii) Expand the service in under-served areas through construction of new health facilities and rehabilitating the existing ones. Currently, the service coverage gap is huge, where there is a need to construct 1,500 new health facilities, rehabilitate 2,460 existing health facilities 59 and upgrade 30% of the existing 3,005 dressing stations and PHC units to Basic Healthy Units (BHUs). In view of available and potential resources the FMOH should commit itself to construct 30% of the planned new health facilities (646), initially (to be increased incrementally as funds become available), rehabilitate and upgrade all targeted health facilities. The rehabilitation programme should also include medical equipment, furniture, transportation means and communication. iii) The strategy shall support increased access to health care, through the injection of additional resources into the existing PHC system, to improve the quality of service and sustain service availability. The support will be in a form of package which shall include technical and material support to the drug supply system to expand coverage and ensure adequate supply of pharmaceuticals and medical supplies for health services. iv) Incentives (cash and non-cash) for re-allocation of health workers to underserved areas as well as to improve health worker performance should be financed. v) Contracting out and contracting in of selected package of PHC services: In areas with no existing government services, the provision of mobile and temporary clinics managed and staffed by government health workers reallocated from better-served areas and States. vi) Another strategy for areas with no government health services is to finance private for profit and non-profit firms and organizations to provide services on a contractual basis. This could include expansion of coverage of services provided by non-governmental organizations (NGOs) already operating in underserved areas. vii) Prioritizing populations with little or no access to facility-based health services, the strategy should support the provision of high-impact health interventions directly to communities and households. This is intended to put knowledge and resources into the hands of households to improve their own health. The focus will be on interventions which do not necessarily require the existence of functioning medical services, thereby reaching populations currently out of reach of facility-based services. Included will be distribution of long-lasting insecticidal nets (LLINs) for malaria prevention in endemic areas which are not served by other programs, micro-nutrient supplementation, safe delivery kits, and information, education, and communication (IEC) on a variety of health issues (see below). Delivery package of health interventions with therefore include pulse delivery of integrated package of interventions (vaccinations, Vit A, LLITN, Re-treatment of nets; promotion of hand washing and breast feeding), in states with low coverage initially, but as time goes on all states will have the capacity to undertake pulse activities to reach all children with interventions. At the same time community capacity building and delivery of health care through community/family methods, especially in the rural areas will be implemented in a few localities initially, but scaled up to eventually achieve national coverage. viii) In areas affected by emergencies, all attempts should be made to ensure that all receive quality PHC services. In this regard, the Emergency and Humanitarian Action directorate, in collaboration with other concerned directorates, should ensure the development of guidelines for service provision in emergency settings. According to risk assessments, enough stocks and supplies should be made available to ensure that PHC services are provided even under the most testing conditions, e.g. by use of mobile teams and mobile facilities. Such measures will certainly need to be backed up by robust communication and logistic arrangements. ix) To ensure that health facilities continue to deliver quality services, the Emergency and Humanitarian Action directorate, with the concerned directorates (mainly PHC and Curative Medicine) should ensure that health facilities are reasonably prepared to deal with foreseen internal and external emergencies. This necessitates the improvement of pre hospital and hospital emergency management systems and plans. These systems will be 60 based upon an assessment of possible threats and an inventory of available resources. Contingency plans are to be tested and updated regularly following conduction of rehearsals and drills, Strategic objective 4: Ensure adequate production, equitable distribution and retention of skilled human health personnel based on the health system needs. Investment in human resource development Interventions will target assessment, planning, production, employment, deployment and management of HRH required to provide PHC services at the national and sub-national levels in a matter that copes the expansion of infrastructure and to sustain the scaling up of services. This requires a multi-pronged strategy and will include: o Strengthen national capacity to support health workforce policy formulation, planning and management, monitoring and evaluation. o Build the capacity of educational institutes of health professions to develop and ensure quality and adequate quantity of health human resource production in response to population needs (Rehabilitation of institutes that produce PHC categories and require urgent interventions (rehabilitation, equipment, improvement of boarding facilities and developing capacities of teaching staff)); Reform SMSB to respond to the huge gap in specialities and sub-specialities. This would require revising the role and policies of the SMSB. Scaling up of external training for specialization and sub-specialization especially for those specialities with marked shortage in training capacities or increased demand (e.g public health specialists). Gaps in skilled work force with limited internal capacity for production will be covered through recruitment of expatriate health workers. Their numbers is to be reduced gradually with the increasing capacity of internal training programmes. Develop an enabling environment to recruit and retain the workforce through improvement of working conditions, including effective incentives, better salaries, career structure, and living conditions (Revision of the salary scale and hardship allowances, and/or special contracts for working in difficult areas, are policy measures that need to be taken in this phase). o Ensure the appropriate staffing of all health facilities at every level of health services with special regard to rural and underserved areas and based on the personnel needs of the health system. o Develop a national system of continuous professional development and continuous career development to ensure ongoing updating of competency for all health personnel recognizing different training need such as leadership and management development, etc. o Strengthen health professionals’ regulation to ensure protection of the public. Strategic objective 5: Ensure equitable coverage and accessibility to quality referral secondary and tertiary health care services at all levels of health care This objective requires interventions at all levels of the health system: • At locality level the focus will be on rehabilitating the district hospitals to provide quality services covering the 4 main basic specialties (Internal medicine, pediatrics, general surgery, and obstetrics and gynecology). • At state level the interventions include rehabilitating the state hospitals to provide quality specialized and priority sub specialized services which includes orthopedics, ophthalmology, renal dialysis, etc as well as availability of automated diagnostic and imaging devices. 61 • At the federal level the strategy target reform of the main federal hospitals to autonomous centres of excellence that fills the gap in specialties in the country and provide training opportunities for under and post graduate students. All secondary care services will be transferred to state level. The three major hospitals (Khartoum, Oumdurman and Khartoum North teaching hospitals) will be upgraded to tertiary care level centres of excellence to accommodate all the remaining sub-specialties. The option of finding new locations and replace the existing old buildings will be explored. • Referral system is an important component facilitated by establishing ambulance network. An effective and workable Referral System needs to be designed and installed with clearly defined functions of each referral level along with patients flow mechanism from and to all levels of care; primary to secondary and tertiary levels and subsequent follow up. The monitoring unit should be strengthened and efficient and effective monitoring system should be designed and implemented. The regulatory system as well needs to be developed and strengthened to regulate the private sector. Strategic objective 6: Reform and develop a pro poor health care financing policies Health care financing reform is the most important policy prerequisite for improving health services and equity. It is recognized that these issues are of concern to the government as a whole, and will require coordination with, in particular, the Ministry of Finance and National Economy. The main required reforms In addition to the strategies and interventions discussed under strategic objective 2 are; • The government’s goal should be to scale up health spending targeting a minimum public health spending to reach 7% of the central government budget; the focus should be on supporting PHC services in underserved areas. • Increases in financial transfers to the states: • Development of a transparent and equitable allocation formula based on sound criteria and indicators • Health financing policy should be revised to be in accordance with the provision of the National Interim Constitution; o Use analytical tools to assess health care financing policies such as national health account analysis and fairness of financial contribution o Promote equitable financing policies including increasing coverage by social and community based health insurance o Promote the use of economic tools and principles in health system planning and management. • Free or subsidized MCH services package is to be costed and delivered at the primary and first referral level. This package should include in addition to the already free services (EPI, Vitamin A, ORS, Malaria, TB, Schistosomiasis, Leishmaniasis, leprosy, onchcerciasis, trypanosomiasis, trachoma, HIV/AIDS, STIs, ANC, family planning, etc): o Treatment of ill child based on IMCI protocol o Normal and caesarian sections o Iron and folic Acid supplementions Strategic Objective 7: Improve the availability to affordable, safe and effective essential medicines 62 Assure the maintenance of quality and safety of all medicines through out the supply chain: This is considered the most important function of the federal and states regulatory authorities. The capacities of drug and pharmacy regulation and control authorities at national and state levels should be enforced. All legislations, standards, specifications, code of practice and guidelines should be developed and updated. Capacities of pharmaceutical inspectorates at federal and state levels must be upgraded. The new National Drug Quality Control Laboratory will be established. Regional laboratories will be rehabilitated. The programme for pre and post marketing surveillance will be expanded. Detailed plans for improvement of hospital pharmacy and human resource development will be implemented. Increase access to medicines by 80% in public health facilities: The National Drug Policy indicates that the public and private sectors should complement each other to attain this objective. An efficient drug supply and storage systems will be established to ensure all public health facilities receive regular quality supply of essential drugs. The health facility coverage by RDF will be increased to 100% in all states. Policies to address the following issues will be developed and adopted: o Promote the role of the private sector in making drugs available o Encourage the local manufacturing of medicines o Reduce the price of medicine and secure accessibility to medical care and medicines Promote rational use of essential medicines in public facilities: the essential drug list should be used at all levels. The rational drug use programme will be introduced into curricula of medical, pharmacy, nursing and health auxiliary schools and in the pre registration training. On-the-job training on rational drug use for all categories will be continued. Strategic objective 8: Introduction and adoption of quality management systems in all health facilities: The interventions will include; • Quality improvement prorogrammes will be set in the targeted facilities. Multiple competency skill-based training will be conducted to clinical and administrative staff. External training will target planning and leadership quality staff. Standards, SOPs, Medical protocols, Manuals will be developed and disseminated. Multidisciplinary quality improvement team concept and applications will be adopted and implemented in federal hospitals. • it is important to integrate the culture of quality improvement within the medical practice. Training and orientation sessions will target all categories of medical staff. It is important to put both patient and employee satisfaction as a goal of the quality management system. A system for their measurement will be put in place. • a system for adverse events measurement will be incorporated within the quality system in hospitals. Patient safety, Infection control, occupational health programmes and guidelines will be strengthened and established at national and facility levels. • Criteria for accreditation will be implemented in hospitals. Orientation sessions in accreditation will be held for healthcare providers. Hospital committees will be trained in accreditation. The hospital accreditation programme will be given the necessary authority to play its role and be supported to be recognized by international bodies (ISQua) Goal 3: Improve child health Strategic objective 9: Reduce child morbidity and morality In order to achieve this goal, strategies have to be designed at two levels of care: a) Primary health care – This should encompass; 63 o Country-wide IMCI services considering the following; Expansion of IMCI in a phased manner, Strengthen commitment of both Federal and State levels to ensure sustainability of IMCI. Investment in institutionalizing a well functioning educative supervision system at state level so that there is a continuous process of skills building of health workers and effective use of IMCI protocols. Establishing a system of annual review of state health systems to find out their responsiveness to IMCI and finding appropriate options to the challenges identified. Introduction of community component where facility-based component is functioning reasonably well. This will also help in tracing dropouts and improve immunization coverage of children. An annual health facility survey to assess turnover of IMCI trained staff and training plan developed accordingly to fill-in the gap besides refresher training of in-service staff. Pre-service training of medical assistant, doctors on the management of common childhood illnesses using IMCI protocols. Active involvement of village midwife and nutrition educators in the community component of IMCI. Distributing ITNs through EPI and health facilities. Conscious efforts to integrate nutrition activities in the areas where services under IMCI strategy have been established. This particularly includes interventions related to breastfeeding, vitamin A supplementation to children between the age of 6-59 months and to women in the postpartum period, training of IMCI trained health workers in nutrition, infant & young child feeding, and reinforcement of growth promotion activities. o Community-based nutrition interventions to combat low birth weight and promote child growth including micronutrient supplementation with vitamin A, iron, folic acid, iodized salts and promotion of exclusive breastfeeding up to six months. o Immunization against the vaccine-preventable diseases of childhood; outreach and home services considering the following; Institutionalize annual micro-planning process up to the locality level. An important element of the micro plans is to explore expanding routine EPI coverage through fixed sites and through mobile and outreach services. Alternative ways to reduce reliance on mobile strategy should be considered. Some of the options could be contracting out services to local NGOs, develop local CBOs and train their staff for delivery of immunization on contractual basis, select female teachers from the local primary schools and train them in immunization along with some monthly incentive, and etc. DPT-HepB-Hib combination vaccines. Booster doses for diphtheria, tetanus (DT) and measles are to be introduced at school entry (6 years of age). EPI surveillance and monitoring generated data is to be critically analyzed and used at all levels in order to derive appropriate evidence-based decisions related to the improvement of the EPI services. Use dropout rate as an indicator of performance (DTP3-DTP1 drop out is presently estimated at 14% and more than half the localities (56%) have drop-out rates higher than 10%). The strategy should emphasize coordination with village midwives and community volunteers for tracing dropouts and un-immunized children and eligible women where possible. New and improved communication strategies are necessary to convince mothers to complete the full immunization schedule for their children. At the same time, an intensified communication effort must be made to support an increased utilization of TT vaccination by women of child-bearing age. The introduction of new vaccines will need to be accompanied by a comprehensive communication campaigns. 64 Advocacy to steadily increase government contribution to the overall EPI cost has to be pursued in order to achieve sustainability of programme implementation. In addition to that, the government shall undertake statewide assessment of non-salary budget to identify shortfalls and find options to fill-in the resource gap. Relevant and effective strategies to reduce vaccine wastages should be developed and implemented (14% of localities report more than 25% DTP wastages). Linkages between the EPI and other programmes such as malaria, reproductive health, IMCI, tuberculosis, nutrition, health education, school health and HIV/AIDS and the disease surveillance system need to be established and further strengthened. Using data quality audit as a method in the evaluation of EPI services in the localities should be maintained and further expanded. The vaccine supply system is to be carefully reviewed in order to prevent stock-outs, presently occurring in 21% of localities. o Efficient village-based midwifery services to improve the quality and access to antenatal care and ensure that every birth is supervised by a skilled birth attendant, in addition to mother and child health services based on primary health care facilities (see below). o Protection against malaria through multiple interventions for women and children. o Behavioral change communication strategies; Initiate advocacy with politicians, decision makers and administrators to apprise them of the benefits of IMCI strategy and for adequate financing, both at national and state level. Develop and implement evidence-based behavioral change communication strategies to improve knowledge, attitude, practice and skills of caretakers and parents of children. The main focus will be on protecting children against vaccine preventable diseases, timely treatment of sick children, care of the newborn children, and use of appropriate preventive interventions against malaria. b) Hospital care – This should include; o hospital-based deliveries; o 24-hour emergency obstetric care; and o Neonatal and pediatric emergency care including management of severe malnutrition. Substantial inputs are required to upgrade existing hospitals infrastructure, training and deploying appropriate human resources to strengthen EmOC and pediatric inpatient care and availing functional ambulance system. Goal 4: Improve Maternal Health Strategic objective 10: Reduce maternal and neonatal mortality and morbidity Efforts should be made to make deliveries safer with professional assistance from skilled birth attendants. Complicated cases should have access to a well equipped health services including EmOC. The core strategic intervention is to strengthen the provision of a “continuum of care” model through addressing the three delays: delay in decision-making to seek adequate medical care during obstetric emergencies, delay in transporting the woman to an appropriate referral hospital and delay in receiving adequate care at the hospital. This entails developing; o Quality midwifery care at PHC level including the community and supported with emergency obstetric care at the referral level. o Upgrade the skills of mid-wives to include the key components of Basic EmOC o Training of one skilled midwife for each village with a population of over 1000. And provide refresher courses to low performers to build their technical capacity. o Midwives should be part of the public sector payroll. A system of supportive supervision should be established. o Registration system of births and maternal deaths through midwives should be developed, this should include verbal autopsy. 65 o A system to provide consumables to midwives needs to be established. o All PHC outlets should be able to deliver quality RH and family planning services to which village midwives could refer clients, particularly; Expanding family planning services as a tool for child spacing and welfare of women. As a first step all outlets should be made eligible for delivery of family planning services. The village midwives could act as change agent and refer clients to health facilities. Referral of high risk pregnancies and deliveries entering into risk. Initiate short in-service training for doctors working in rural hospitals in management of complications of pregnancy, anesthesiology and Caesarian section (C/S). Upgrading rural and referral hospitals with necessary equipment. Develop and implement protocols and standard operating procedures for EmOC, ANC, delivery and postnatal care. Conduct mapping of midwifery services aiming at identifying gaps in services provision, skills, and training needs. Prioritization of states for expansion of reproductive health services. The RPI can be a good indicator to prioritize investments for expanding reproductive health services. 66 Goal 5: Combat HIV/AIDS, TB, Malaria and other diseases Strategic objective 11: Ensue early preparedness and response to emergences and epidemics The interventions should include; a) Response to epidemics: o Upgrade and maintain the role of the federal epidemiology department to provide the national leadership and technical reference. o Improve early preparedness systems for rapid emergency response to outbreaks; o Develop a comprehensive epidemic contingency plan at national and states level o Train rapid assessment and response teams at state and district levels o Improve rapid laboratory confirmation of outbreaks through systematic collection, transportation and processing of medical samples collected from the suspected cases, with a strategy to build up the capacity of public heath labs in selected geographical zones and at the level of the states. o Review the ongoing sentinel-based surveillance system to ensure its representative to epidemic-prone areas, sensitivity and timeliness and that the results utilized for improvement. The system should be upgraded to integrate the exiting systems into a comprehensive system. Priority should be given to strengthen the system in south Sudan and other war-affected areas. o Avail buffer stock supply (10% of the annual consumption of drugs, diagnostics and insecticides) at national and in epidemic-prone areas o Adopt reactive mass vaccination strategy of the high risk population against circulating diseases when applicable. o Improve the logistic and stock capacity of the epidemiology departments to be able to rapidly respond to the operations that necessitates logistic work. o Establish / activate functioning partnership committees b) Response to emergences: o The capacity of the Emergency and Humanitarian Action (EHA) directorate should be raised to enable it to lead the efforts of raising the capacity of the health sector to manage emergencies. Early preparedness, and possibly prevention, of emergencies relies upon qualified staff conducting thorough risk mapping and vulnerability analyses to come up with priorities and contingency plans targeted to the needs of each region. These plans should then be supported fully (financially, supplies and equipment, and buffer stock) and they should also be tested and updated by conduction of regular rehearsals and drills. Coordination with other stakeholders should be promoted and sought throughout the different phases of this process. This will build up a stronger early warning and information management system, and will ensure the presence of more effective preparedness and response activities. In addition to regional contingency planning, contingency plans should be developed with the concerned directorates which address possible future threats and/or pandemics, e.g. avian influenza. Strategic objective 12: Reduce HIV/AIDS transmission HIV/AIDS control and prevention o Availing of voluntary confidential counseling and test services. o Provision of high-quality STI services based on syndromic management approach o Treatment of opportunistic infections in PLWHA including TB o Availing ARV therapy for AIDS cases and for prevention of vertical transmission. o Educate youth using life skills curriculum to improve their knowledge, attitude, skills and behavior towards high-risk practices. 67 o Establishing well-focused behavioral change communication interventions. o Screening of blood and blood products o Ensuring surgical procedures and injection safety. o Delivery of an appropriate service package to high-risk population sub-groups. Strategic objective 13: Reduce Malaria related morbidity and mortality Malaria control o The interventions will be based on the global strategy for malaria control; Institutionalize the implementation of standardized outpatient treatment protocols. A systematic plan for training of general practitioners, both in public and private sector in using the treatment protocols should be enforced. An annual assessment should be undertaken to monitor implementation of protocols. Develop and implement a policy for community level prevention and treatment of malaria. Village midwife could be trained to provide intermittent preventive treatment to pregnant women and treat adult patients. A standardized treatment protocols for hospitalized complicated malaria cases should be developed. An appropriate training programme have to be implemented to orient hospital staff i.e. specialists, general duty doctors and nurses. Verbal autopsy of each hospital death from malaria should be made mandatory in order to assess lapses in the quality of care so that improvements could be made on ongoing basis. Simultaneously, the malaria case fatality rate of each hospital should also be monitored on annual basis with an objective to bring it down to less than 1% in every hospital. Vector control using suitable measures will be strengthened at all levels. Emphasis to distribution of ITNs, treatment and re-treatment of nets will be at all levels. The strategy will also target expansion of biological control in all irrigated areas and strengthening environmental management component. Early warning system, early detection and containment of epidemics shall be given priority in unstable malaria's areas in addition to areas in the South witnessing high rate of returnees. Design and implement BCC campaigns focusing on encouraging early and proper care seeking for malaria, use of ITNs especially to protect pregnant women and children under five and the use of intermittent preventive treatment by the pregnant women with SP. It important to train healthcare providers in interpersonal communication techniques. Annual planning workshops should be held inviting state malaria control program managers and partner NGOs for analysis of epidemiological data and design annual operational plans. Improve the performance of blood smear microscopy in low performing states, either in terms of skills development of staff or supply of consumables or establishment of laboratory facilities. The GFATM funds earmarked for establishing state reference laboratories is an important step towards improving the quality of diagnostic services. The program has already established linkages with IMCI, RH and EPI. It is hoped that these linkages will be further strengthened. Exemption policy for charging anti-malarial drugs is an important pro-poor policy to be implemented. Home management of malaria 68 Strategic objective 14: Reduce Tuberculosis related morbidity and mortality TB control o The interventions will be based on DOTS strategy. TB-DOTS service will be integrated within the PHC essential package. Emphasis should be given to the following; Gradually expand TB-DOTS to all public health facilities (including facilities run by military and police forces) and integrate it within the essential PHC package. Adopting DOTS/ community based dots to respond to TB/HIV,MDR-TB and other challenges (DOTS Plus) Strengthen supportive supervision of diagnostic and treatment centers to improve the quality of services, reduce time lag in reporting, sample checking of DOT at patient level and tracing patients who default from treatment. This would require procurement of new vehicles, motorbikes and bicycles, provide operating cost for operational vehicles, make available reporting and monitoring tools, and provide on-the- job training. Strengthen quality of sputum microscopy at TB diagnostic centers and state referral laboratories through in-service training and supply of equipment. The purpose is to institutionalize a system for random checking of sputum positive and sputum negative slides from all diagnostic centers with a timely feedback for corrective measures including reinforced supportive supervision and retraining, when and where needed. Strengthen and make functional a two-way referral system of complicated/suspected TB cases. The activities comprise; adaptation of WHO guidelines and training of pediatricians/chest physicians/medical officers in management guidelines. Design and implement a behavioral change communication strategy targeting suspected TB cases and their families to improve their knowledge, care seeking behavior and adherence to treatment. Empowering patients and communities (ACS) Enabling and promoting research and Tuberculin/MDR/ TB-HIV surveillance. Strategic objective 15: Reduce Schistosomiasis related morbidity and mortality Schistosomiasis control The control strategy will be based on WHO guidelines. The epidemiological situation prevailing in each state will determine the scale and scope of interventions. Priority should be given to capacity building and establishing control unit to supervise and conduct the epidemiological and control activities. Design and implement a behavioral change communication strategy to raise awareness and to improve the care seeking behavior of the population in the affected areas Develop partnership and intersectoral collaboration to address main health determinants related to the disease. Conduct epidemiological surveys to determine the pattern of morbidity and mortality related to Schistosomiasis and inform decision making. Strategic objectives 16: Control /Eradicate / Eliminate other communicable diseases Other communicable diseases: The strategy will target eradication of Dracunculiasis, elimination of leprosy and control of Leishmaniasis, Lymphatic Filariasis, Onchocerciasis and 69 sleeping sickness. Integrated approved strategies of communicable diseases interventions will be followed, including prevention, early detection, diagnosis and treatment, containment of epidemics promotion of nutrition, healthy lifestyles, clean environment, surveillance system, early warning and forecasting systems. For LF: The Global Strategy to eliminate Lymphatic Filariasis is absed on: To interrupt transmission by using a combination of anti- filarial drugs given in a single annual dose (Mectizan and albendazole in much of sub- Saharan Africa, or diethylcarbamazine (DEC) and albendazole in the rest of the world). To alleviate the suffering caused by the disease. o Basic hygiene to prevent and treatment of acute attacks. o Nursing- care for the patient Vector control. Health Education. For Sleeping Sickness: the control strategy will be based on; Mapping Surveys using CATT and CIAT and microscopy. Management of cases and vector control. Raise the population awareness towards the disease control. For Leishmaniasis: the strategy will be based on; Active case detection of the disease with increased access to diagnostic and treatment facilities. Vector control (integrated with Malaria). Raising awareness of the community about the disease. Goal 6: Promote a comprehensive approach to Health Strategic objectives 17: Promote healthy life style and reduce the burden of non communicable diseases a) To increase early detection of targeted non-communicable diseases: This will be done through institutional capacity building of NCD programme at national and state levels. The HMIS and research will be strengthened to form national registries for these diseases. A key strategy is to integrate the management of these diseases within the PHC facilities. b) To raise community awareness towards healthy life styles by 30%, and promote behaviour & practice change: through an effective information education communication strategy to address risk factors and increase participation in regular physical activity. The numbers of tobacco, alcohol and snuff users are to be reduced by working in partnership with health authorities/boards and local communities. Laws and legislations will be actively developed and implemented and the role of religious values and Scholars 'fatwas' that prohibit these practices will be activated. c) Extension of the basic package of school health services: this will target students and schools with a basic preventive and pomotive package of services (health check ups, vaccination, Vitamine A, school water and sanitation). It will be done in collaboration with Ministry of Education. d) Health promotion workplace programmes: The main strategies are to build the institutional capacity of the national Occupational/Workplace Directorate, set legislations and regulations that promote safety at workplace and identify the specific needs of small to medium sized enterprises in relation to workplace health e) Support policies addressing the health needs of special groups: through strengthening the national and regional structures that address the health promotion needs of young and elderly people, working in partnership and consultation with the young people to 70 develop and implement a strategy to promote their health and develop strategies to care the elderly within their families & communities Goal 7: Creation of an environment conducive to partnership building and streamline the role the private sector Strategic objective 18: Encourage private sector (for profit & not for profit) in contributing in health care provision and promote its collaboration with the public sector: f) Increase the contribution of the private sector in care provision, focusing on filling the gabs (primary, secondary and tertiary care): this will be done through development of policies and legislations that ensures full synergy and collaboration between the two sectors. The private sector will be encouraged to invest in areas where the public sector is insufficient. Models of public private partnership will be explored and adopted. The private sector will be contracted for both medical and non medical services to complement the public sector in areas of need. g) The government is required to address the issues related to the private sector such as; quality control, ensuring fair competition, price moderation, regulations and public private partnership. h) Enforcement of policies that regulate the practice of government employees in the private sector. Strategic objective 19: Support environmental health and development of community based approaches for achieving health goals in partnership with other sectors: i) National councils and coordination mechanisms will be formed. The decentralized system in environmental management will be strengthened with emphases on capacity building at locality level. Capacity for policy development, regulations and guidelines will be enhanced. Modes of partnership (e.g. with private sector for waste disposal) will be explored and implemented. Strategies to address issues of healthy cities -towns and villages, healthy market places and promotion of food safety, CBIs, raising income of the poor, preventing road traffic accidents, pollution, safe water supply and wasted disposal will be developed and implemented. Proper health legislations and regulations should be enforced. j) Community-based emergency management should be promoted. This includes forming of committees and continuous training and monitoring activities to ensure that, at least in the most vulnerable areas, communities are better prepared to deal with the emergencies unique to their special circumstances. This also involves selection of volunteers which will conduct assessments and response activities and who will be the backbone of the early warning system and the information system in general. 71 11 Projects/ programmes Key activities Components Defined Quantity Institutional capacity building and improving governance function of the FMOH o Conduct short- and long-term training of FMOH staff in key areas (leadership in health; health system development; governance, equity and health; health financing; human resource development; organization and management; use of information for informed decisions; and project management) Ext. long training Ext. short training Int. long training Int. short training 12 100 100 200 o Provide technical assistance to Strengthen governance function ( health legislation and regulation, standard setting, partnership building ) STP/year 4 o Provide technical assistance to Strengthen Management systems development (financial management, personnel management, drug management, procurement and logistics, monitoring and supervision; referral system, health information management; etc) STP/year Capital cost 2 o Provide technical assistance to strengthen policy and systems research and conduct priority health system researches STP/year Policy research 2 10 o Rehabilitate physical infrastructure and equipment of administrative of offices (information technology including computers and accessories, vehicles, renovation and construction). o Develop system for National Health Accounts and conduct 2 rounds Strengthening & reorganization of SMOH & local health directorates o Setting the Administrative Structures At state & localities ( LHMTs) according to the standard o Provide training and capacity development of the state and local directorate managers and managers of state and rural hospitals ( strategic and operational planning; personnel, financial and logistic management system development; monitoring and supervision; community mobilization and participation) Ext. long training Ext. short training Int. long training Int. short training 50 200 200 3000 o Provide technical assistance to Strengthen governance function and systems development ( management systems in the SMOH and local health directorates, financial, personnel, logistics management systems, referral system, monitoring and supervision, drug and contraceptive supply, and repair and maintenance). o Provide technical assistance to Strengthen Policy and operational and research and conduct priority health system researches o Redeployment and recruitment of staff (incentives shall be provided to recruit staff on a contractual basis in 72 Components Defined Quantity order to develop the necessary capacity to organize and deliver health services). o Rehabilitate physical infrastructure and support to all the SMOHs and local health directorates (renovation and construction of administrative offices, supply of computers and accessories, office furniture and vehicles). Office rehab, Office equip Vehicles 93 93 279 Promote the culture of research and provide evidence for policy and decision making. Meetings of the national research council meetings 10 Implementation of research leadership program Training, staff, equips Develop the national research priority agenda Meetings workshops 15 2 Establish institutional technical and ethical review committees at Federal and states level institutes Meetings 10 Training in research methods, research ethics, evidence for policy and decision making, scientific writing … Workshops Fellowships 30 40 Implementation of research career path program Fellowship, promotions, rewards Small grants for junior researchers Small grants 50 Supportive environment Equips, buildings, Connectivity, subscription Development of data bases, publications Software, data collection, issuing journals and newsletters Investment in infrastructure and equipment; Expand universal coverage and geographic access of basic package of health services o Undertake needs assessment, especially at the state and local levels to improve the condition of the physical infrastructure and equipment. o Investing in building new health facilities in areas of low coverage • 313 HCs • 318 Basic health units (BHU) • 15 RHs Number of HCa Number of BHUs Number of RH 313 318 15 o Rehabilitation of 3,005 (dressing stations and PHC units) and upgrading 39% of them to basic health units Number of DS & PHC units 3005 o Rehabilitation of 2103 existing health facility (HC, BHU) to enable it to deliver the essential minimum PHC package Number of HC& BHU 2103 o Rehabilitation of 350 rural hospitals specially for EmOC Number of RH 350 o In service training of 2,460 Medical assistants of RHs, HC, and BHU in integrated training to deliver essential PHC package (the focus will be on IMCI and SOC) In service training course 123 o Training of 11,487 midwives in ANC, FP and EPI to expand their role in delivering the PHC package at community level In service training course/ locality 88 o Provide essential medicines, consumables and supplies in accordance with BPHS medicines, consumables and supplies 73 Components Defined Quantity o Deploy essential staff in all health facilities according to standard guidelines o arrange with non-governmental actors (contracting out, contracting in) o mobile clinics No of mobile clinics 180 o injection of resources into the existing health system – in particular personnel incentives and drug supply – in order to reactivate services Investment in human resource development o Strengthen national HRH directorate to support health workforce policy formulation, planning and management, evaluation and monitoring. o Rehabilitation of institutes that produce PHC categories and require urgent interventions (rehabilitation, equipment, improvement of boarding facilities, etc); (state branches) 25 o Produce quality and adequate quantity of health human resource production based on the 10 yrs strategic plan for HRH Number of HW trained: Nurses (basic training)/5 years MAs (basic training)/5 years Doctors (local basic specialty) /5 yrs Doctors (abroad basic specialty) /5 yrs Doctors (local sub - specialty) /5 yrs Doctors (abroad sub- specialty) /5 yrs Nurses/MA (local basic specialty) /5 yrs Nurses/MA (abroad basic specialty) /5 yrs 22,500 5,000 3000 750 15 550 250 125 o Provide adequate incentives to teachers and supervisors; Procure and distribute textbooks and other learning material; 25 o Plan in-service training after an assessment of learning needs o Revision of the salary scale and hardship allowances, and/or special contracts for working in difficult areas, o Avail jobs to recruit the appropriate staffing of all health facilities at every level of health services and with special regard to rural and underserved areas and based on the personnel needs of the health system. o Develop a national system of continuous professional development and continuous career development Ensure equitable coverage and accessibility to quality referral secondary and tertiary health care services at all levels of health care o Avail standard list of essential equipment, furniture, basic supplies and consumables to district and state hospitals Equipment sets (district) Furniture sets (district) Equipment sets (state) 134 134 25 74 Components Defined Quantity Furniture sets (state) Basic supplies and consumables Rehabilitation (district ) Rehabilitation (states) 25 134 25 o Avail ambulances See below o Develop and implement referral guidelines ad system o Reform federal hospitals into autonomous sub specialized centres of excellence (partnership) Turn key projects 3 o Expand triage system to cover all federal, state and district hospitals. No of hospitals 50 Reform and develop a pro poor health care financing policies Provison of free/ subsidized service package targeting mothers and children Introduction and adoption of quality management systems in all health facilities: Targeted on- the- job training in quality issues Workshops Fellowships 50 10 Development standards, SOPs, Medical protocols, Manuals Document development, printing, dissemination 10,000 Formation of multidescplinary quality teams meetings 1000 Patient and employee satisfaction surveys Surveys in 20 hospitals 20 Adverse event measurement system Surveys in 20 hospitals 20 Establishment patient safety prorogrammes in all tertiary and secondary care hospitals Training, formats Establishment infection control prorogrammes in all tertiary and secondary care hospitals Training, formats, research Establishment of the programme of hospital accreditation Training, standards, surveys Strengthen national and establish quality department at state level Recruit and train staff 40 improve the availability to affordable, safe and effective essential medicines Target: Assure the maintenance of quality and safety of all medicines through out the supply chain Build capacities of pharmacy regulation authorities and pharmaceutical inspectorates at national and state levels Training, office and equip 25 All legislations, standards, specifications, code of practice and guidelines and policies Document development, printing, dissemination, training 500,000 Establish new National Drug Quality Control Laboratory and rehabilitate regional laboratories Buildings, equips 1 pre and post marketing surveillance programme expanded Training, sampling Strengthen hospital pharmacies and human resource development. Workshops, training Target: Increase access to medicines by 80% in public health facilities 75 Components Defined Quantity Establish drug supply and storage systems Logistics, training, stores 25 state Expand/ introduce RDF Logistics, supply, buildings 25 Target: Promote rational use of essential medicines in public facilities Introduction of rational drug use into curricula Workshops, document development On the job training on rationale drug use for all categories Training workshops 50 Information dissemination and public awareness ICE EPI o Expand routine immunization services network to provide services for un reached children & women ( 25- 60 % of the target population ) Transport, social mobilization, programme Management, maintenance & overheads o Secure availability of sufficient staff (personnel & training) Recruit 250 qualified vaccinators in 134 localities. o Cost for service providers (fixed, outreach, mobile, supervision, trainings) o Eradicate polio through; polio campaigns Vaccines & operational costs o Conduct catch up and follow up campaigns to eliminate Measles Vaccines & operational costs o Conduct campaigns for MNT elimination in identified high-risk localities. Vaccines & operational costs o Introduce New Vaccines(Hepatitis B & Pentavalent) Vaccines 24,966,568 doses o Routine Vaccines Avail vaccine Injection supplies Vaccines DTP, BCG,OPV,MEASLES,TT Syringes & safety boxes 63,888,231 doses 49,505,298 o Cold Chain: Procure adequate quantities of cold chain equipment and spare parts, conduct preventive maintenance and establish maintenance workshops Equipments 15,241 (solar fridges, ice-lining, cold rooms, freezers, monitors, cold boxes, vaccine carriers o Strengthen disease surveillance for Polio AFP surveillance & other EPI diseases IMCI o Supporting the core team with trained facilitators for SCM courses and follow up team leaders: • Conduction of IMCI SCM course for doctors to select potential facilitators.(10 courses) • Conduction of facilitator's technique course doctors.( 10 courses • Conducting one course for follow up supervisors doctors.( 10 courses) Course Course course 10 10 10 o Availing supervisors to strengthen the supervisory system in the state (Training of supervisors for routine supervision) 76 Components Defined Quantity o Conduction of facilitator's technique course community health promoters trainers(30 courses): course 30 o Training of care providers to cover all health facilities: • Training of all care providers in SCM courses for 11 days.(135 courses) • Conducting first Follow up rounds for all care providers.(135 rounds) Course course 135 135 o Conducting refresher 3 days courses for care providers who had old training (two years) courses o Ensuring availability of IMCI Drugs, equipments and reporting forms: • Providing IMCI kits to all health facilities (4500HF) • Providing all rural hospitals and IMCI implementing health facilities with oxygen concentrator and nebulizers (124 RH) • Providing recording forms, daily register and monthly report to IMCI implementing health facilities. Kits O2 conc. & Nebulizers Registration books 4,500 124 o Conducting quarterly supervisory visits to all IMCI implementing health facilities at state level. o Introduction of IMCI community component in at least one locality in each state. • Conducting planning workshop at locality level to Select one community for implementation(122 workshops) • Conducting KAP studies in each locality(122 studies) • Training of CHPs in the selected communities(268 courses) • Conducting post intervention survey Courses Study Courses 122 122 268 o Dissemination of IMCI messages through mass media and schools: • Distributing IMCI T.V and radio program spots through media • Distributing IEC materials for schools o Introduction of IMCI strategy in the curriculums of the medical schools & medical ass. Schools: • Conduction orientation workshops in all remaining schools ( 20 medical & 13 medical ass. Schools) • Availing the logistic needed for adoption of the strategy (33 schools) Courses 33 Improve Maternal Health Increase percent of Service Delivery Points (SDP) providing ANC FP (more than 3 methods) from 16% to 90% o Rehabilitation, establishment and equally redistribute health centers and basic health units to meet the standards of maternal care GIS- mapping, Office rehab and building, o Provision of the health facilities and the community with Training of HVs 400 77 Components Defined Quantity the needed human resources to provide quality ANC/FP services Training of AHVs In-service training for MAs (see HRH) 1500 o Provision of equipment and supplies including drugs to the health facilities and midwives to cope with ANC/FP service provision. Midwifery kits lab kits for routine investigations 9,000 16,000 o Provide outreach services to remote areas Vehicles/Ambulances, 400 o Conducting regular facilitative supervision o Organization of in-service competency-based training courses (CPD) o Provision of Guidelines and standards for maternal services management to all Care Delivery Points (CDP) Printing of Hands out, pamphlets, posters, wall charts o Assessment and removal of the cultural barriers that hinder the use of services Surveys Increase coverage of villages with more than 1000 population by skilled personnel to 90%. o Availing 9000 Skilled birth attendants to the villages Training of SBA (18 months 9000 o Organization of competency-based training courses (CPD) in-service training 600 o Conduct assessment for the status of village midwives performance currently in service (11847) Training needs assessment 30 rounds o Incorporation of VMWs into the health system Salary/5 year Ensure that 70% of referred cases have timely and quality services (strengthen the referral system), Increase institutional deliveries and C/S rates o Rehabilitation, establishment and equally redistribute rural hospitals to meet the standards of maternal care GIS- mapping, Office rehab and building o Provision of blood transfusion services to RH hospitals (See HIV below) o Provision of human resources to the RH to cope with Emergency Obstetric Care and provide training in EmOC Course 80 o Sustainable provision of the minimum needed supplies including drugs to the RH to cope with Emergency Obstetric Care S/E including consumables 250 o Provision of Guidelines and standards for EmOC services to RH Printing of Hands out, pamphlets, posters, wall charts o Training of the Care Providers (RH) on the Guidelines and standards for maternal services management In service training course 80 o Establish a village emergency fund at community level to support referral Sensitization campaign and seed money Strengthen Individuals, Families and Communities involvement to support maternal and neonatal Health (MNH) and overcome harmful traditional practices that affect the health of girls and women at least in the catchment's areas of health facilities providing midwifery services o Strengthen and sustain the knowledge and capacity of youth (Secondary Schools graduates) in Orientation workshops, Seminars and training courses 15 workshop 78 Components Defined Quantity understanding MNH needs and risks 60 seminars 264 courses o Establishment of local networks between community based organizations, non-governmental organizations, community leaders and governmental bodies Orientation workshops, Seminars, training courses 60 workshop 120 seminars 264 courses o Carry out KAP studies to identify community specific HTPs Surveys One /State (15) o Carry out behavioral change campaigns targeting the identified community specific HTPs IEC materials and campaigns Ensue early preparedness and Ensue early preparedness and response to emergences and epidemics o Assessment of the ongoing sentinel-based surveillance system Survey o Upgraded sentinel-based surveillance system to a comprehensive system S&E, Training and Logistics o Develop a comprehensive epidemic contingency plan at national and states level o Train rapid assessment and response teams at state and district levels Courses o Avail buffer stock supply (10% of the annual consumption of drugs, diagnostics and insecticides) at national and in epidemic-prone areas Drugs and consumables o Establish / activate functioning partnership committee and conduct regular meetings with stakeholders (all partners) at states level o build up the capacity of public heath labs in 7 geographical zones o Malaria o Effective case management o Improve Malaria diagnosis through: • Rehabilitation of 25 malaria reference labs enabled to carry out QA for microscopy and RDTs • Provide RDTs kits • Training of health facilities personnel (At least one/health facilities) • Training on malaria microscopy • Avail S&E for microscopy • Training abroad for 12 senior lab personnel to lead the diagnosis of malaria at national and sub-national level Number Kits Number Number S&E Number 25 2,500 2,500 12 o Improve management of Malaria cases through • Avail the malaria treatment protocol to public and private health facilities (in form of booklets, posters and bench-aid) • Wall chart on Guidance to manage severe malaria Number Hospitals 8,800 350 79 Components Defined Quantity cases • Incorporate The malaria treatment protocol into all medical, pharmacy and lab science schools curricula • Train all health personnel every 2 year (related to treatment) • Build a functioning drug distribution system in all states • Avail drugs (36 million doses of ACTs (1st, 2nd …) and 4 million treatment package for severe malaria) • Develop a system to provide mothers (care providers) with free ACTs • Pilot HMM project using different approaches • Establish a system for post-marketing surveillance once per year for each anti-malarial drug for any registered drug brand Courses Drug o Improve Integrated Vector Management through: • Spraying of 95,000 houses (IRHS) every year at least once using appropriate insecticide • Procure and distribute in collaboration with partners 5.7 million LLNs free of charge in rural settings using COMBI methodology • Avail 2 million doses of nets treated/ re-treated freely (so 400,000 nets treated every year) • Establish a system for regular entomological survey at all level (NMCP, SMCP and Districts) • Establish 10 insectaries and entomological labs established at national and regional levels • Integrate Malaria vector control fully with other vector control diseases at the locality level with endorsement of IVM concepts • Train all vector control personnel at all level at least one day training every year • 15 public health officers/ scientists trained to work as entomologist at regional and nation level (fellow ship, Diploma, MSC…) • 30 public health officers trained to lead IVM at national and state level (Diploma, MSC…) • Avail one pump / worker, one truck-mounted machine / 100,000 population, one car per locality and one car per state for IVM at any time • Procure and distribute 20,000 kg, 7,000 litres, 15,000 litres and 425,000 doses of insecticides to be used for IRS, chemical larviciding, space spraying and treatment/ re-treatment of nets respectively for use on annual basis according to WHOPES specifications ITN Impregnation tablet Lab. Courses Fel. Int training S&E S&E 5,700,000 400,000 10 15 30 Epidemic containment o Review the ongoing sentinel-based surveillance system 80 Components Defined Quantity to ensure its representative to epidemic-prone areas, sensitivity and timeliness and the results utilized for improvement o Develop Malaria epidemic contingency plan at states and national level o Train rapid assessment and response teams at state and district levels (3 from each epidemic-prone state/ district) Courses o Avail buffer stock supply (10% of the annual consumption of drugs, diagnostics and insecticides) at national and in epidemic-prone areas Drugs Capacity building, advocacy and partnership o Establish / activate a functioning partnership committees o Conduct regular meetings of the RBM taskforce (all partners) at states level o Train for all states at least one person for diploma in malariology (2 courses, each 20 persons needed) Course 2 o Train at least one person in ICCP (9 months diploma) in each locality (120 persons need to be trained) Int. diploma course 120 o Train 12 personnel from national and states for the regional training course in Bandar Abbass ( planning malaria control programmes) Short Ext. training 12 o Advocacy to malaria control maintained (by biannual newsletter, annual report, Africa/ World malaria day, National Week, press release …) o At least 10 Operational researches carried out (4 case management, 4 IVM and 2 others) Training course 10 HIV/AIDS o Conduct BCC and advocacy campaign including life skills training , peer education and awareness sessions targeting policy makers , community leaders , Young people and general public Cost of Radio , TV spots 100,000 Cost of life skills training per young person 100,000 Cost of awareness raising and advocacy session 100,000 Cost of IEC material 10,000,000 o Delivery comprehensive service package to most at risk population sub-groups including promotion of safer sexual practice Estimated Cost of comprehensive package per person 1,000,000 o Improve STIs management through procurement and distribution of drugs , training of HWs and operational research Cost of drugs per pat 100,000 o Provide kits, logistics , trained personnel and monitoring tools for 100% safe blood transfusion Cost of screening one blood unit 500,000 o Cost of training of one provider 1000 o Establishment and expansion of VCT services to 720 sites Cost of establishing one VCT 720 o provide ARV and OI treatment and nursing care for 20,000 HIV/AIDS patients Cost of ARVs per patients per year 20,000 81 Components Defined Quantity TB o Expand gradually TB-DOTS to all public health facilities and integrate TB-DOTS services as part of the essential PHC package (avail free drugs) o Strengthen educative supervision of diagnostic and treatment centers (procurement of new vehicles, motorbikes and bicycles; provide operating cost for operational vehicles; make available reporting and monitoring tools; and provide on job educative supervision) S&E o Strengthen quality of sputum microscopy of state referral laboratories (in-service training and supply of equipment). Courses o Training of pediatricians/chest physicians/medical officers of teaching hospitals in use of treatment guidelines, provide anti-TB drugs. Courses o Design and implement a behavior change communication strategy using private sector advertising agencies, (BCC messages through electronic and print media, and interpersonal communication. o Expand TB-DOTS through health facilities of Ministries of Interior and Defence to provide access to additional 4.5 million employees and their families working in Defence and police force and to jail inmates in 36 prisons. (Establishment of 40 diagnostic and 240 treatment centers; training of staff; provision of anti-TB drugs, reagents and consumables; and monitor implementation). Enabling and promoting research and Tuberculin/MDR/ TB-HIV surveillance. Control /Eradicate / Eliminate other communicable diseases o Diagnosis, treatment Drugs and consumables: leishmania leprosy LF GW (filters) onchcerciasis SS Containment of epidemics promotion of nutrition, healthy lifestyles, clean environment, surveillance system, early warning and forecasting systems. See above Vector control. Equipment and supplies Mapping and epidemiological surveys Mass drug administration (LF, SS, Onco.) Running cost of MDR campaigns Goal 7: promote healthy life style and reduce the burden of non communicable diseases 82 Components Defined Quantity Reduce the morbidity and mortality related to non communicable diseases o Baseline surveys for priority NCD and risk factors Cost of survey 5 o Establishment of national registries and strengthening HMIS Cost of system in state 15 o Integration of NCD within the basic PHC package Cost of training one provider Cost of equip/unit 5000 5000 o Developing and implementing nationwide initiatives like “Towards a Tobacco Free Society” and “Towards a snuffing Free Society” Advocacy materials logistics 10,000,000 o Establishment of IEC center Buildings, staff and equipment o Introduction of the basic school health package Equipment and Supplies IEC materials and curricula o Develop and implement the priority strategies and policies: health promotion policy, young and elderly people, workplace, environment and pollution…) Cost of taskforce meetings o Development and endorsement of targeted legislations and regulations o Establishing partnership with relevant bodies to develop a healthy village/town model [healthy hygienic houses, streets]. And piloting it Meetings, TA, logistics o Development and implementation of interventions for a health workplace TA, development of guidelines and regulations training Creation of an environment conducive to partnership building and promotion of the role the private sector Encourage private sector (for profit & not for profit) in contributing in health care provision and promote its collaboration with the public sectors: Increase the contribution of the private sector in care provision, focusing on filling the gabs: development of private sector policies and legislations taskforces Piloting public private partnership Contracting out of services Bidding for medical and non medical services Strengthening of systems (MHIS, licensing, quality control…) Logistic support Enforcement of employment policy compensation Support development of environmental health and community-based approaches for achieving health goals partnership with other sectors: Formation of the High National Council and Forum of Health Promotion and states councils meetings 20 Capacity building of environmental health structure at locality, state and national levels Training Infrastructure 15 Development of surveillance systems for food safety, chemical safety and industrial waste management Equipment training Development of manuals, protocols and guidelines TA, logistic support 83 Components Defined Quantity Healthy cities projects pilot Development of environmental strategies and legislations Research and pilot projects studies Community based development initiatives Development of coordination mechanisms and councils at all levels Meetings and logistics Awareness raising IEC material 10,000,000 84 12 Costing and resources required for financing the 5 year strategy: Costing the MDGs has received significant attention from leading agencies in the health such as WHO and development partners such as the World Bank. Generally there are two approaches and methodologies for costing; either a top-down or a bottom up approach. In both methodologies, key steps have to be followed which include problem definition, service description, identification, measurement and valuation of resource use27. We have to admit beforehand it is a daunting undertaking; hence it is difficult to come up with the exact cost. Therefore the figures we are presenting are the best possible estimates. Our costing work has befitted from other exercises undertaken by the WHO (CMH recommendation), the World Bank (Development Goals: History, Prospects and Costs')28 and the United Nation Millennium Project. 1. In a first step, we identified goals strategic objectives and targets 2. Second we identified key strategies and interventions such as the provision of services, goods, and infrastructure necessary to meet the Goals. They include sets of interventions that are required to meet the Goals, such as improving access and coverage to health services. We used unit cost identified in previous exercises such as the JAM and the MDTF and updated these unit costs based on new knowledge and prices changes. 3. Third, we identified quantitative targets for each intervention for 2011, such as coverage rates or health outcomes related, for instance to reduce maternal mortality and the number of teachers, classrooms, and learning materials required to ensure universal primary education and the expansion of secondary education. 4. Fourth, we estimate the capital and operating costs of the health related MDGs and other health interventions, including human resources and infrastructure. We project an exponential scaling up of interventions to allow for a gradual expansion of service delivery capacity 5. Fifth, we iteratively revise needs estimates to integrate synergies across intervention areas that would affect overall MDG investment needs. 6. six we used available data on health expenditure to calculate current levels of spending 7. In a final step, we develop a financing strategy by matching MDG investment needs with substantially increased domestic resource mobilization compared to current levels of spending to estimate the MDG financing gap. 27 The main methodological issues in costing health care services, Centre for Health Economics University of York, Zsolt Mogyorosy, Peter Smith 28 World Bank Policy Research Working Paper, “Development Goals: History, Prospects and Costs,” by Shantayanan Devarajan, Margaret J. Miller, and Eric V. Swanson. 85 We emphasize here what has already been concluded by the CMH recommendations that health is not an ultimate effect of economic growth; it is a cause for development and economic growth. Health is also a key input to economic development because it raises the productivity of the work force and increases the attractiveness of the economy for investors, domestic and foreign. Pandemic diseases such as malaria, TB, and AIDS not only increase suffering but deter investments in infrastructure, tourism, agriculture, mining, and industry29. Exercise done in other low income countries showed that achieving the health-related MDGs will require are around $13–$25 per capita in 2006, rising to around $30–$48 in 2015 29 Investing on development: a practical plan to achieve the millennium development goals: UN millennium project 2005 Estimate the capital and operating costs Use available data on health expenditure to calculate current levels of spending Key strategies and interventions identified Quantitative targets for each intervention Develop a financing strategy by matching: MDG investment needs Available resources Calculate gaps Goals strategic objectives and targets identified 86 Estimation of resources needed for the strategy (in million US$) Y-2006 Y-2007 Y-2008 Y-2009 Y-2010 Y-2011 GDP current prices (million) US$ 34,120 45,605 53,780 62,435 70,545 79,710 Population (million) 36.4 37.1 38.0 39.0 40.0 41.0 Exchange rate 225 200 200 200 200 200 GDP annual growth rate 9.0 10.0 7.6 7.0 7.2 7.1 Total government expenditure (million) US$ 8,618 11,795 13,095 14,020 14,880 16,030 Expected allocation for health based on the assumption resources will increase from 5 7% of GGE (million US$) 431 649 786 911 997 1,122 Other resources expected (donors and multilateral agencies) for health in million us$ 93 100 107 116 125 Total resources expected (Government + donors and multilateral) million US$ 741.48 885.45 1,018.79 1,112.72 1,246.69 Resources need to finance essential interventions to achieve the MDGs+ 927.50 1045.00 1179.75 1331.00 1500.70 Resources need to finance Major infrastructure (loans and Grants) 92.75 114 140.4 172.8 212.544 Total resource required in million US$ 6716.45 1020.25 1159.00 1320.15 1503.80 1713.25 Resource Gap in million US$ 1711.33 278.78 273.55 301.36 391.08 466.56 Estimation of resources needed for the strategy (in terms of US$ per capita) Y-2006 Y-2007 Y-2008 Y-2009 Y-2010 Y-2011 Per capita expected allocation of resource for health 11.84 17.49 20.68 23.37 24.92 27.37 Other resources expected (donors and mulitlateral agencies) for health percapita US$ 2.5 2.63 2.76 2.89 3.04 Total resources expected (Government + donors and multilateral) per capita US$ 19.99 23.30 26.12 27.82 30.41 Resources need to finance essential interventions to achieve the MDGs+ in per capita 25 27.5 30.3 33.3 36.6 Resources need to finance major infra structure in per capita 2.5 3.0 3.6 4.3 5.2 Total resource required in per capita 27.50 30.50 33.85 37.60 41.79 Resource Gap in per capita 7.51 7.20 7.73 9.78 11.38 87 Y-2006 Y-2007 Y-2008 Y-2009 Y-2010 Y-2011 GDP current prices (million) US$ 34,120 45,605 53,780 62,435 70,545 79,710 Total government expenditure (million) US$ 8,618 11,795 13,095 14,020 14,880 16,030 expected allocation of resource for health as % of government budget 5% 5.5% 6% 6.5% 6.7% 7% Per capita expected allocation of resource for health 11.84 17.49 20.68 23.37 24.92 27.37 Expected resources allocated for health as % of the GDP 1.26 1.42 1.46 1.46 1.41 1.41 Other resources expected (donors and multilateral agencies) for health per capita US$ 2.5 2.63 2.76 2.89 3.04 Total resources expected (Government + donors and multilateral) per capita US$ 19.99 23.30 26.12 27.82 30.41 Resources need to finance essential interventions to achieve the MDGs + in per capita 25 27.5 30.3 33.3 36.6 Resources need to finance major infra structure in per capita 2.5 3.0 3.6 4.3 5.2 Total resource required in per capita 27.50 30.50 33.85 37.60 41.79 Total resource required) as % of GDP 2.24% 2.16% 2.11% 2.13% 2.15% Total resource required as % of government budget 8.65% 8.85% 9.42% 10.11% 10.69% Resource Gap in per capita 7.51 7.20 7.73 9.78 11.38 Country macroeconomic scenario and the cost of the health MDGs: The macroeconomic outlook has been favorable and stable during the last 5 years with annual growth of about 7% and expected to keep growing with the same pace. Further the macroeconomic policy for the coming 5 years has identified achieving the MDGs and attaining poverty reduction as key priority. We modeled our costing to the macro economic scenario and projected the expected resources and the financing gaps. 88 Resources required for the 5 year strategy and achieving the health-related MDGs Y-2006 Y-2007 Y-2008 Y-2009 Y-2010 Y-2011 GDP current prices (million) SDD 7,677,000 9,121,000 10,756,000 12,487,000 14,109,000 15,942,000 GDP current prices (million) US$ 34,120 45,605 53,780 62,435 70,545 79,710 Population (million) 36.4 37.1 38.0 39.0 40.0 41.0 Exchange rate 225 200 200 200 200 200 GDP annual growth rate 9.0 10.0 7.6 7.0 7.2 7.1 Total expenditure government expenditure (million) SDD 1,939,000 2,359,000 2,619,000 2,804,000 2,976,000 3,206,000 Total expenditure government expenditure (million) US$ 8,618 11,795 13,095 14,020 14,880 16,030 Expected allocation for health based on current trend (5%) million SDD 96,950 117,950 130,950 140,200 148,800 160,300 Expected allocation for health based on current trend (5%) million US$ 430.89 589.75 654.75 701.00 744.00 801.50 Per capita expected allocation of resource for health 11.84 15.90 17.23 17.97 18.60 19.55 Expected resources allocated for health as % of the GDP 1.26 1.29 1.22 1.12 1.05 1.01 resources need to finance essential interventions to achieve the MDGs the MDGs+ 25 27.5 30.3 33.3 36.6 Other resources expected for health (donors and multilateral agencies) 2.1 2.21 2.32 2.43 2.55 Resource Gap 7.00 8.06 9.96 12.24 14.50 89 Components Y2007 Y2008 Y2009 Y2010 Y2011 Total 5 years Improve governance of the health system 14,094,294 15,973,534 18,416,545 21,141,441 24,336,148 93,961,962 Institutional strengthening and improved governance in FMOH 1,976,814 2,240,389 2,583,037 2,965,221 3,413,299 13,178,760 Strengthening & reorganization of SMOH &local health directorates 11,551,703 13,091,930 15,094,225 17,327,554 19,945,940 77,011,350 Promote the culture of research and provide evidence for policy and decision making. 565,778 641,215 739,283 848,667 976,910 3,771,852 - - - - 0 Investment in infrastructure and equipment: 67,854,384 76,901,635 88,663,062 101,781,576 117,161,903 452,362,560 1-Infrastructure (physical and equipment) needs assessment, especially at the state and local levels 170,415 193,137 222,676 255,623 294,250 1,136,100 313 HCs 6,857,987 7,772,385 8,961,102 10,286,980 11,841,457 45,719,910 318 Basic health units (BHU) 3,870,855 4,386,969 5,057,917 5,806,283 6,683,676 25,805,700 15 RHs 2,738,813 3,103,988 3,578,715 4,108,219 4,729,016 18,258,750 Upgrading of 3,005 (dressing stations and PHC units) to basic health units 18,289,181 20,727,739 23,897,864 27,433,772 31,579,320 121,927,875 Rehabilitation of 2103 existing health facility (HC, BHU) to enable it to deliver the essential minimum PHC package 18,885,634 21,403,718 24,677,228 28,328,451 32,609,194 125,904,225 Rehabilitation of 350 rural hospitals specially for EmOC 17,041,500 19,313,700 22,267,560 25,562,250 29,424,990 113,610,000 2-Provide integrated training and in service training of PHC worker, MA, MW 787,804 892,845 1,029,397 1,181,706 1,360,275 5,252,028 3- Provide essential medicines, consumables and supplies in accordance with BPHS 24,345,000 27,591,000 31,810,800 36,517,500 42,035,700 162,300,000 4- Out reach services (mobile teams, clinics, etc…) 12,488,985 14,154,183 16,318,940 18,733,478 21,564,314 83,259,900 Investment in human resource development 23,967,653 27,163,340 31,317,733 35,951,479 41,384,147 159,784,350 Ensure equitable coverage and accessibility to quality referral secondary and tertiary health care services at all levels of health care 131,540,904 149,079,691 171,880,115 197,311,356 227,127,294 876,939,360 Reform and develop a pro poor health care financing policies (Provision of free/ subsidized service package targeting mothers and children) 85,207,500 96,568,500 111,337,800 127,811,250 147,124,950 568,050,000 Introduction and adoption of quality management systems in all health facilities: 520,983 590,447 680,751 781,475 899,564 3,473,220 90 Components Y2007 Y2008 Y2009 Y2010 Y2011 Total 5 years improve the availability and access to affordable, safe and effective essential medicines 61,585,547 69,796,953 80,471,781 92,378,320 106,337,710 410,570,310 EPI 43,033,828 48,771,672 56,230,869 64,550,742 74,305,076 286,892,187 Goal 3. Improve child health 1,012,495 1,147,495 1,322,994 1,518,743 1,748,242 6,749,969 Goal 4. Improve Maternal Health 62,354,362 70,668,276 81,476,366 93,531,542 107,665,198 415,695,744 Increase percent of Service Delivery Points (SDP) providing ANC FP (more than 3 methods) from 16% to 90% 7,741,710 8,773,938 10,115,834 11,612,565 13,367,353 51,611,400 Increase coverage of villages with more than 1000 population by skilled personnel to 90%. 48,203,830 54,631,008 62,986,338 72,305,746 83,231,947 321,358,869 Ensure that 70% of referred cases have timely and quality services (strengthen the referral system), Increase institutional deliveries and C/S rates 5,626,130 6,376,280 7,351,476 8,439,194 9,714,450 37,507,530 Strengthen Individuals, Families and Communities involvement to support maternal and neonatal Health (MNH) and overcome harmful traditional practices that affect the health of girls and women at least in the catchment's areas of health facilities providing midwifery services 782,692 887,051 1,022,717 1,174,038 1,351,448 5,217,945 Early preparedness and Ensue early preparedness and response to emergences and epidemics 1,911,083 2,165,894 2,497,148 2,866,624 3,299,802 12,740,550 Malaria 40,140,036 45,492,041 52,449,647 60,210,054 69,308,462 267,600,240 Effective case management 39,802,614 45,109,630 52,008,749 59,703,921 68,725,847 265,350,762 Epidemic containment 52,342 59,321 68,393 78,513 90,377 348,945 Capacity building, advocacy and partnership 285,080 323,091 372,504 427,620 492,238 1,900,533 HIV/AIDS 25,148,385 28,501,503 32,860,556 37,722,578 43,422,878 167,655,900 TB 4,321,238 4,897,403 5,646,417 6,481,856 7,461,337 28,808,250 Control /Eradicate / Eliminate other communicable diseases (leishmania, leprosy, LF-GW, onchcerciasis, SS) 11,198,700 12,691,860 14,632,968 16,798,050 19,336,422 74,658,000 Promote healthy life style and reduce the burden of non communicable diseases and reduce the morbidity and mortality related to non communicable diseases 8,943,623 10,136,106 11,686,334 13,415,434 15,442,655 59,624,151 - - - - 0 91 Components Y2007 Y2008 Y2009 Y2010 Y2011 Total 5 years Building partnership for heath and promote the role the private sector 21,387,204 24,238,831 27,945,947 32,080,806 36,928,573 142,581,362 Encourage private sector (for profit & not for profit) in contributing in health care provision and promote its collaboration with the public sectors: 12,917,579 14,639,923 16,878,970 19,376,368 22,304,353 86,117,192 Environmental health and community-based approaches for achieving health goals partnership with other sectors: 8,469,626 9,598,909 11,066,977 12,704,438 14,624,220 56,464,170 Sub total 641,844,006 727,423,207 838,676,168 962,766,010 1,108,250,651 4,278,960,043 Salaries 372,762,975 422,464,705 487,076,954 559,144,462.5 593,935,673.5 2,485,086,500 Total resources 1,014,606,981 1,149,887,912 1,325,753,122 1,521,910,472 1,702,186,325 6,764,046,543 92 13 Implementation, Monitoring and Evaluation framework: The implementation of the plan will take place at all levels of the health system. Annual plans will be developed in consultation with all related partners. The planning process will be bottom –up and top-down planning and it will build on the FMOH experience in developing micro- plans with the states and localities. There will be an annual micro-planning process for all localities to be followed by the annual planning meeting for the states. The national annual plan will be based on state's plans. This strategy will serve as guidelines and directives for states and localities plan to address the national priorities, objectives and targets. Most of the implementation activities will take place at state and locality level. The federal level will carry the stewardship function to supervise and provide guidance to the states and localities. Capacity building of states and localities especially in planning and monitoring and evaluation is an important element in assuring the implementation of the plan. The plan will be monitored regularly. The indicators listed in the table below will for the base for the M&E. Annual, mid-term and end term reports will be developed. The monitoring process will depend on the regular reports of the HIS as well as the reports of the programs and departments. Part of the indicators will be assessed only at the mid-term or end-term evaluations (see the table below). This will be done through surveys as well as reports. There will be some national surveys such as; MICS at the end of plan HIV/AIDS sero-prevalence and behavioral survey (baseline-end term) Nutritional surveys (mid term and end term) Annual public expenditure reviews 2 rounds of the NHA Tuberculin survey (baseline- end term) Prevalence surveys for communicable diseases (mid term and end term) For assessing the financing of the health system the NHA is an important tool. Fortunately the FMOH availed funds through the MDTF/ MOFN funded health project to develop NHA. The success of the M&E system will depend to a greater extent on improving the HIS, the integrated disease surveillance system and the reporting and communication system. 93 M&E indicators, baseline and targets Indicators defined baseline target Notes Method of data collection Periodicity Responsible bodies Strategic objective 1: Strengthening the governance and institutional capacity of the decentralized health system at all levels # Of staff at FMOH/SMOH/LHA trained and currently working in the areas of management and leadership. Ext. long Ext. short Int. long Int. short 50 200 200 500 Reports Annual FMOH # of management sub-systems developed and implemented by the FMOH/SMOH/LHA (Supervision, procurement, supply and logistics, HIS, M&E, performance appraisals, accounting, personnel management, etc) Sub-systems 10 Reports Annual FMOH # of policies developed and implemented by the FMOH /SMOH /LHA TBD TBD Reports Annual FMOH # of sub-national health councils/administrative units established Administrativ e units 159 Reports Annual FMOH Strategic objective 2: promote the culture of researches and provide evidence for policy and decision making. % of budget allocated for health researches Percent <2 % >2% Reports Annual FMOH Number of health professionals conducted/ participated in health research TBD TBD Reports Annual FMOH Availability of up- to- date local health research database Up-to-date database 1 1 Reports Annual FMOH Number of professionals trained EB policy/decision making/practice number 20 500 Reports Annual FMOH Number of health research council meetings meetings 3 10 Reports Annual FMOH Number of functioning ethic review committees 1 20 Reports Annual FMOH Strategic objective 3: Ensure equitable coverage and accessibility to the essential PHC package. Percent of population living within 5 kilometres of a PHC facility. Percentages 41% 70% Estimation Micro-planning process Baseline Midterm- end term FMOH, SMOH, LHAs Health facility- population ratio 1/14000 1/11000 No and % of primary HC facilities providing quality basic health care package. Percentages 22% 63% Micro-planning process Baseline Midterm- end term FMOH, SMOH, LHAs 94 Indicators defined baseline target Notes Method of data collection Periodicity Responsible bodies Strategic objective 4: Ensure adequate production, equitable distribution and retention of skilled human health personnel. % increase in training capacity for each category of allied health personnel 3090 7,000 Reports Annual FMOH Number produced of each category of health personnel: MAs Midwives Nurses Doctors (local specialization) Doctors (specialization abroad) Nurses (post basic training locally) Nurses (post basic training abroad) Doctors (sub-specialization abroad) Numbers/yr 320 1100 1250 80-100 50 TBD TBD TBD 1500 1750 4500 400 150 50 25 110 Reports Annual FMOH Strategic objective 5: Ensure equitable coverage and accessibility to quality referral secondary and tertiary health care services at all levels of health care No of district/state hospitals providing basic/priority speciality services No TBD 134 Reports Annual FMOH, SMOH, LHAs No of states with functioning referral/ central ambulance systems No 1 25 Reports Annual FMOH, SMOH, LHAs % increase in availability of sub-speciality services Percentages TBD TBD Reports Annual FMOH, SMOH, LHAs % / No of hospitals (public/private) joined/ accredited by the accreditation programme No /% 0 50% Reports Annual FMOH, SMOH, LHAs No of hospitals implementing triage system No 3 40 Reports Annual FMOH, SMOH, LHAs Strategic objective 6: Reform and develop a pro poor health care financing systems Health expenditure as a percentage of national budget Percentages 1.8% 7% Estimation Expenditure survey/ NHA / reports annual FMOH Health expenditure as a percentage of GDP Percentages ? 1 % 2.5% Estimation Expenditure survey/ NHA / reports annual FMOH Per capita health expenditure (in US$) Dollars ? 20 > 40 Estimation Expenditure survey/ NHA / reports annual FMOH Mean public sector per capita expenditure Dollars ? 9-10 20-25 Estimation Expenditure survey/ NHA / reports annual FMOH 95 Indicators defined baseline target Notes Method of data collection Periodicity Responsible bodies Strategic objective 7: To improve the availability to affordable, safe and effective essential medicines %/ no. of states implementing post marketing surveillance programme No of states 6 25 Reports Annual FMOH, SMOH, % of population with access to medicines % <40% 80% Surveys end term FMOH Number of states with a functioning revolving drug fund system No of states 1 25 Reports Annual FMOH, SMOH, LHAs % of contribution of local drug manufacturers % 24% 40% Reports Annual FMOH, SMOH, LHAs % reduction in adverse drug reactions % TBD TBD Surveys end term FMOH Strategic objective 8: Introduction and adoption of quality management systems in all health facilities % of HF running. quality improvement prorogrammes Tertiary care 2ry 1ry 0 0 100% 50% 10% Reports Annual FMOH % of HF running infection control prorogrammes Hosp/ % 29 (8%) 357 (100%) Reports Annual FMOH % of HF running patient safety prorogrammes Hosp/ % 29 (8%) 357 (100%) Reports Annual FMOH Adverse events/Hospital infection rate TBD TBD Reports Annual FMOH %/Number of hospitals (public/private) joined/ accredited by the accreditation programme Public hosp Private hosp 23 (6%) 0% 80% 20% Reports Annual FMOH Strategic objective 9: Reduce under-five mortality rate to 70 per 1,000 live births by 2011 Prevalence of severe under-weight, stunting and wasting in under five years of age Under-Wt% Stunting% Wasting% 8.6% 14.6% 3.3% >6% >10% >2.2% Nutrition surveys Mid term survey End term survey FMOH Under-five mortality rate Rate/1000 122 70 (2006 estimates) MICS End term FMOH- CBS UN Agencies Infant mortality rate Rate/1000 77 60 MICS End term FMOH- CBS UN Agencies Proportion of 1-year-old children immunized against measles Percentage 72% 90% Reports - MICS Annual- End term FMOH, SMOH, LHAs - UN Agencies Proportion of 1-year-old children immunized with DPT3 Percentage 83% 90% Reports - MICS Annual- End term FMOH, SMOH, LHAs - UN Agencies % of localities with DPT3 & HepB3 coverage of at least 80% # 58% 100% (2004) Reports Annual FMOH, SMOH, LHAs no of confirmed wild polio cases # 0 0 Reports Annual FMOH, SMOH, LHAs 96 Indicators defined baseline target Notes Method of data collection Periodicity Responsible bodies % reduction in measles cases/100,000 population Percent Measles eliminated Reduction in measles incidence Reports Annual FMOH, SMOH, LHAs no of localities reporting < 1 case of neonatal tetanus/1000 live births # 89% 100% Reports Annual FMOH, SMOH, LHAs % of children under 5 who received at least one dose of Vit. A annually. Percentage 76% 90% 2006 estimates Reports - MICS Annual- End term FMOH, SMOH, LHAs - UN Agencies Strategic objective 10: Reduce maternal and neonatal mortality and morbidity Maternal mortality ratio Rate/100,00 0 638 260 2006 estimates MICS End term FMOH- CBS UN Agences Neonatal mortality rate Rate/1000 33 20 MICS End term FMOH- CBS UN Agences Proportion of births attended by skilled health personnel Percentage 57% 90% MICS End term FMOH- CBS UN Agences % of pregnant women who received prenatal and postnatal care % Prenatal % Postnatal 68.7%, 13% 90% 40% Reports - MICS Annual- End term FMOH, SMOH, LHAs - UN Agencies Institutional deliveries Percentage 19.6% 25% Reports - MICS Annual- End term FMOH, SMOH, LHAs - UN Agencies C/S rate Percentage 2.4% 5% (1999 estimates) Reports - MICS Annual- End term FMOH, SMOH, LHAs - UN Agencies % of referral facilities providing quality EmOC. Percentage 49% 70% (2005 estimates) Reports Annual FMOH, SMOH, LHAs % of SDP providing ANC/FP Percentage 16% 90% (1999 estimates) Reports Annual FMOH, SMOH, LHAs Percent of villages (> 1000 population) covered with SBA Percentage 43% 90% Mapping survey- Micro planning Baseline Midterm- end term FMOH, SMOH, LHAs CPR Percentage 7.7% 35% (2006 estimates) MICS End term FMOH- CBS UN Agences Strategic objective 11: Ensue early preparedness and response to emergences and epidemics % of states/ localities with a functioning units for emergency/epidemics preparedness and response No. of epidemics detected and aborted within the accepted standards No. ? 90% Reports/ surveillance Annual FMOH, SMOH, LHAs 97 Indicators defined baseline target Notes Method of data collection Periodicity Responsible bodies system No / % of health facilities that submit regular reports No. /Percentage ? 90% Reports Annual FMOH, SMOH, LHAs Strategic objective 12: Reduce HIV/AIDS transmission HIV prevalence among pregnant women attending ANC clinics Percentage 1% 1% HIV/ AIDS behavioral and epidemiological survey Baseline- end term FMOH Number of children orphaned by HIV/AIDS Orphaned children 63,000 ? HIV/ AIDS behavioral and epidemiological survey Baseline- end term FMOH Percentage of women and men aged 15 – 49 who both correctly identify ways of preventing the transmission of HIV and who reject major misconceptions of about HIV/AIDS (By rural and urban) 45% 90% MICS- HIV/ AIDS behavioral and epidemiological survey End term FMOH- CBS UN Agencies Percentage of young women and men aged 15-24 reporting the use of a condom the last time they had sex with a non-marital ,non-cohabiting sexual partner <10% 70% MICS- HIV/ AIDS behavioral and epidemiological survey End term FMOH- CBS UN Agencies Number of people among most-at-risk target populations reached through BCC/counselling session(s) (By target population) Reports Annual FMOH Percentage of health facilities which are applying STIs Syndomic Approach 25% 60% Reports Annual FMOH Number of clients (By age & sex) received HIV test results and post test counselling 1,000,000 Reports Annual FMOH Percentage of blood banks(public & private) providing HIV blood screening services using standardized protocols (By existing & new established 100% 100% Reports Annual FMOH Number of people (By sex, age, pregnant women & children, new & follow-up) with advanced HIV infection receiving antiretroviral combination therapy 400 20,000 Reports Annual FMOH Number of HIV orphaned and vulnerable children whose households received free basic external support in caring for the child 0 5,000 Reports Annual FMOH Number of government sector(s) and private sector has strategic plan with budget for HIV/AIDS in place with a HIV units within 12 30 Reports Annual FMOH 98 Indicators defined baseline target Notes Method of data collection Periodicity Responsible bodies functional HIV/AIDS unit Federal Ministries Amount of external funds disbursed and utilized by all the other partners for the HIV/AIDS programmes and activities (Disaggregated by disbursed & utilized in US Dollars Dollars 200,000,0 00$ 4,000,000 $ in 2006 Reports Annual FMOH Strategic objective 13: Reduce Malaria related morbidity and mortality Prevalence and death rate associated with malaria Percent reduction 50% 2000 figures Reports / surveys Annual – mid term- end term FMOH Proportion of malaria risk areas using effective malaria prevention and treatment measures Percentage 90% MICS End term FMOH- CBS UN Agencies % of population in high risk areas who have access to effective anti-malarial treatment according to the National Treatment Protocol Percentage 90% Reports / surveys Annual – mid term- end term FMOH % of pregnant mothers and children < 5 years of age in high transmission areas have access to effective preventive measures Percentage 80% MICS/ surveys mid term End term FMOH- CBS UN Agencies % of health facilities' laboratories with improved malaria microscopy/ availability of rapid diagnostic tests. Percentage 90% Reports Annual FMOH % of states with well functioning Malaria control Department Percentage 100% Reports Annual FMOH Strategic objective 14: Reduce Tuberculosis related morbidity and mortality Incidence of tuberculosis per 100,000 people Percentage 1.8% 1% Tuberculin survey mid term End term FMOH Proportion of TB cases detected and cured under directly observed treatment short-course Detection rate/100 Cure rate/100 44.3% 81% 70% 85% Reports Annual FMOH Strategic objective 15: Reduce Schistosomiasis related morbidity and mortality Schistosomiasis prevalence among the school children in endemic areas. Percentage >40% <10% Periodical Surveys mid term End term FMOH Strategic objective 16: Control /Eradicate / Eliminate other communicable diseases No of new leishmania cases detected and treated No. 8,000 5,000 Reports Annual FMOH No of new guinea worm cases detected and contained No. North South 0 5,000 0 0 Reports Annual FMOH 99 Indicators defined baseline target Notes Method of data collection Periodicity Responsible bodies No of localities with less than 1% prevalence of lymphatic Filariasis Percentage Prevalence surveys End term FMOH No of localities with less than one leprosy case/10,000 population No. ? All localities Reports Annual FMOH Strategic Objective 17: Promote health life styles and reduce the burden of non communicable disease Prevalence of non communicable diseases % of HPT % of DM % of cancer % of CVD 1.5 1 0.2 < 1.5 <1 <0.2 MICS End term FMOH- CBS UN Agencies Prevalence of Tobacco, snuffing and alcohol use % of tobacco use % of snuffing MICS End term FMOH- CBS UN Agencies Number of schools enrolled in the school health programme Number of schools Reports Annual FMOH Number of rules and legislations endorsed Reports Annual FMOH Strategic objective 18: Encourage private sector (for profit & not for profit) in contributing in health care provision and promote its collaboration with the public sectors: % contribution of the private sector in specific services % form total utilization % from bed capacity 20 17 40% 40% Surveys Mid term end term FMOH Strategic objective 19: Build partnership with other sectors and support environmental health and development of community-based approaches for achieving health goals: No of developed policy/ strategy/ legislations Number of endorsed documents Reports Annual FMOH No of active coordination councils/bodies % of active locality councils % of active state councils 1 for each state/ locality Reports Annual FMOH 100 101 14 References 15 Acknowledgements: 16 Annexes 1 DHS 1990 2 SHHS, 2006 3 DHS 1990 4 SHHS, 2006