IMPLEMENTATION OF NATIONAL DEVELOPMENT

STRATEGIES; SUDAN PRESENTATION

الرحيم الرحمن الله بسمTHE REPUBLIC OF SUDAN

ECOSOC MEETING, GENEVIA6-10-2009

Outlines of the presentation

• Sudan Background• Key Features of HS in Sudan• MDGs; indicators and efforts• Main challenges and

Recommendations

Background

Shares borders with9 countries; free movement across most of these borders

Vast country; surface area 2.5 million km²

Background

• 40 millions population (2008 census), scattered scanty populated settings

• Massive population movement and displacement (civil conflict, drought, desertification and major floods)

Background

• High adult illiteracy rate (mainly women)

• Low population awareness on health issues

Three tiered health system/ Decentralized federal system

FEDERAL STATE (15 N/10 S)

LOCAL/DISTRICT (> 200)

Formulation of National policies, plans and strategies; resource mobilization, overall monitoring and evaluation, coordination, supervision, training and external relations.

Formulation of State’s policies, plans and strategies, according to federal guidelines, funding and implementation of plans

Implementation of national/state policies and service delivery, based on the primary health care approach

Three tiered health system

FEDERAL STATE (15 N/10 S)

LOCAL/DISTRICT (> 200)

Formulation of National policies, plans and strategies; resource mobilization, overall monitoring and evaluation, coordination, supervision, training and external relations.

Formulation of State’s policies, plans and strategies, according to federal guidelines, funding and implementation of plans

Implementation of national/state policies and service delivery, based on the primary health care approach

Three tiered health system

FEDERAL STATE (15 N/10 S)

LOCAL/DISTRICT (> 200)

Formulation of National policies, plans and strategies; resource mobilization, overall monitoring and evaluation, coordination, supervision, training and external relations.

Formulation of State’s policies, plans and strategies, according to federal guidelines, funding and implementation of plans

Implementation of national/state policies and service delivery, based on the primary health care approach

Three tiered health system

FEDERAL STATE (15 N/10 S)

LOCAL/DISTRICT (> 200)

Formulation of National policies, plans and strategies; resource mobilization, overall monitoring and evaluation, coordination, supervision, training and external relations.

Formulation of State’s policies, plans and strategies, according to federal guidelines, funding and implementation of plans

Implementation of national/state policies and service delivery, based on the primary health care approach

Financing of the health system

• Low public health spending;– 13.5 US$/ capita

(around 5% of government expenditure)

– high out of pocket expenditure > 60%

– Fragmentation (multiple providers e.g. MOH, Police, HI, ……………)

Public Health Spending, 2006

FMOH$3.6827%

SMOHs$5.1538%

Localities$0.252%

Armed Forces$2.6820%

Social Security Funds

$1.7313%

Public Health Spending, 2006

FMOH$3.6827%

SMOHs$5.1538%

Localities$0.252%

Armed Forces$2.6820%

Social Security Funds

$1.7313%

Multiple Actors/Partners

Heath Coordination Councils, at all levels of the health system, with adequate representation of all

partners to oversee the development of health policies and strategies and monitor the

implementation

Human resources for Health

• 1.5 care providers/1000 population

• Disproportional production of HRH (6 doctors to one nurse) with huge gap specially for AH W Catego

ryCurren

t estima

tes

Target by 2013

Gap

Doctors (speciali

st)

1000 5000 4000

Nurses 16,000 80,000

64,000

Midwives

16,629 26,000

9,371

Other AHWs

6,000 26,000

20,000

Total 47,663 144,400

96,737

source.; 10 year HRH Strategy

• High turnover (specially doctors)

Human resources for Heath

Khartoum State56%

Other States44%

Distribution of Doctors

• Marked inequality in distribution

Coverage and accessibility to PHC

services• Wide disparities

in geographic coverage with PHC units

Percentage of Pop. Living within 5 Km from the nearest functioning health facility, Mapping survey 2008

Goal 1: Eradicate Extreme Poverty and Hunger

Target 2: Reduce by half the proportion of people who suffer from hunger

Indicator 4: Prevalence of Underweight Children Under Five Years of Age (UNICEF)

Child Malnourishment (Severe Underweight), SHHS 2006

3.5

22.1

9.4

0

2

4

6

8

10

12

14

16

18

20

Kharto

umGez

ira

Centra

l Equ

ator

ia

Lake

s

sout

h Kor

dofa

n

River N

ile

North

Kor

dofa

n

South

Dar

four

Gadar

if

Whi

te N

ile

Sinaar

Sudan

Blue N

ile

Wes

t Equ

ator

ia

Red S

ea

North

ern

East E

quat

oria

Wes

t Dar

four

War

rab

North

Dar

four

Kassa

la

Upper

Nile

Jong

olei

Wes

t Bah

r El-g

azal

Norht

Bah

r El-g

azal

Unity

State

%

Goal 2: Achieve Universal Primary Education

Target 3: Ensure that all boys and girls complete a full course of primary schooling

Primary School Net Attendance Ratio (NAR) ,

SHHS 2006

4.3

91.1

53.7

05

101520253035404550556065707580859095

100

State

%

Children Reaching Grade 5 , SHHS 2006

13.2

98.290.3

0

10

20

30

40

50

60

70

80

90

100

110

Nor

ht B

ahr

El-g

azal

Lake

sU

nity

War

rab

Eas

t E

quat

oria

Wes

t Bah

r E

l-gaz

alW

est E

quat

ori

aC

entr

al E

quat

oria

Red

Sea

Riv

er N

ileU

pper

Nile

Sud

anN

orth

ern

Nor

th D

arfu

rB

lue

Nile

Jong

olei

Wh

ite N

ileS

inaa

rK

assa

laG

ezir

aW

est D

arfu

rso

uth

Kor

dofa

nS

outh

Dar

fur

Nor

th K

ordo

fan

Gad

arif

Kha

rto

um

State

%

Goal 3:Promote Gender Equality and Empower Women

Target 4: Eliminate gender disparity in primary and secondary education preferably by 2005, and at all levels by 2015

Indicator 9: Ratio of Girls to Boys in Primary, Secondary, and Tertiary Education

Education Gender Parity (Primary Education ) , SHHS

2006

0.43

1.060.93

0

0.2

0.4

0.6

0.8

1

1.2

State

%

Goal 6. Combat HIV/AIDS, Malaria and Other Diseases

Target 8: Halt and begin to reverse the incidence of malaria and other major diseases

Knowledge of preventing HIV Transmission , SHHS 2006

4.0

24.6

0.00.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

18.0

20.0

22.0

24.0

26.0

state

%

28.8

82.5

49.4

0

10

20

30

40

50

60

70

80

90

Uni

ty

NB

GE.

Equ

ator

iaW

arab

Upp

er N

ile

WB

G

Lake

sW

. Dar

fur

Blu

e N

ileG

adar

ifW

hite

Nile

Jong

lei

N. K

ordo

fan

Kas

sala

Sinn

arK

hart

oum

S. K

ordo

fan

Red

Sea

Gez

ira

N. D

arfu

rS.

Dar

fur

Nor

ther

nR

iver

Nile

C. E

quat

oria

W. E

quat

oria

Ave

rage

Under-fives sleeping under insecticide-treated nets ,

SHHS 2006

Goal 7: Ensure Environmental Sustainability

Target 10: Reduce by half the proportion of people without sustainable access to safe drinking water

Use of improved water sources, SHHS 2006

56.1

Use Of Sanitary Means Of Excreta Disposal, SHHS 2006

1.9

83.2

31.4

05

1015202530354045505560657075808590

State

%

Goal 4: Reduce Child Mortality

Target 5: Reduce by two thirds the mortality rate among children under five

Indicators 13, 14: Infant &Under-Five Mortality Rate

Infant Mortality Rate, SHHS 2006

Gezira 52.37Kassala 56.29White Nile 56.49Northern 57.40North Kordofan 60.55Sinaar 62.24Unity 63.93South Darfour 67.18River Nile 68.58North Darfour 68.71Khartoum 68.99Northern States 70.99Red Sea 73.42Jongolei 73.76Sudan 80.77Upper Nile 82.40East Equatoria 82.69Gadarif 86.34Lakes 89.5West Darfour 92.83West Bahr El-gazal 96.89south Kordofan 98.01Blue Nile 99.24Southern States 102.41Central Equatoria 106.96Norht Bahr El-gazal 129.23Warrab 137.88West Equatoria 150.7

56.29 56.49 57.40 60.55 62.24 63.93 67.18 68.58 68.71 68.99 70.99 73.42 80.77 82.40 82.69 86.34 89.5 92.83 96.89 98.01 99.24 102.41 106.96129.23 137.88

52.37

150.7

73.76

020406080

100120140160180200220240

Stat

%

52.3780.77

150.7

020406080

100120140160

Under-five Mortality Rate, SHHS 2006

62.81

112.16

192.11

0

20

40

60

80

100

120

140

160

180

200

220

Gez

ira

North

ern

Kassa

laUni

ty

Kharto

um

North

Kor

dofa

n

White

Nile

River N

ile

North

Dar

four

South

Dar

four

Sinaa

r

North

ern

State

s

Jong

olei

Upper

Nile

Sudan

Lake

s

East E

quato

ria

Red S

ea

West

Bahr E

l-gaz

al

South

ern

State

s

Gad

arif

West

Gar

four

Centra

l Equ

ator

ia

sout

h Kor

dofa

n

Norht

Bah

r El-g

azal

Warra

b

Blue

Nile

West

Equato

ria

State

%

Goal 5:Improve Maternal Health Target 6: Reduce by three quarters the

maternal mortality ratioIndicators;16: Maternal Mortality Ratio17: Proportion of Births Attended by Skilled

Health Personnel19c: contraceptive prevalence

Contraceptive Prevalence

0.1

22.4

7.6

0

5

10

15

20

25

State

%

Births Attended by Qualified Health Personnel

19.9

98.2

58.1

0

20

40

60

80

100

120

Nor

ht B

ahr

El-g

azal

Jong

olei

Eas

t E

quat

oria

Cen

tral

Equ

ator

iaU

nity

Wes

t Dar

fur

Upp

er N

ileLa

kes

War

rab

Wes

t Bah

r E

l-gaz

alB

lue

Nile

Sou

th D

arfu

rS

udan

Wes

t Equ

ato

ria

sout

h K

ordo

fan

Kas

sala

Gad

arif

Nor

th D

arfu

rS

inaa

rN

orth

Kor

dofa

nR

ed S

eaG

ezir

aW

hite

Nile

Kha

rto

umR

iver

Nile

Nor

ther

n

State

%

Maternal Mortality Ratio

93.6

2327.2

1106.7

0

500

1000

1500

2000

2500

No

rther

n

Riv

er N

ile

Re

d S

eaN

orth

Ko

rdof

an

Kha

rtoum

Sin

nar

No

rth D

arfo

ur

Gaz

ira

Whi

te N

i leS

outh

Ko

rdof

an

Blu

e N

ile

Gad

arif

Wes

t Dar

four

Kas

sala

Sou

th D

arfo

ur

Un

ityE

ast

Equ

ato

ria

Jou

ngle

iC

ent

ral E

quat

oria

Up

per

Ni le

War

abN

orth

Ba

hr A

l-Gaz

alW

est B

ahr

Al-G

azal

Lake

sW

est E

qua

tori

a

Sud

an

States

%

Efforts and opportunities; Policies

• National Health, RH and Child health policies

• Making life-saving care free:• Declaration of free treatment for U5s, CSs and delivery

care

• Revision of the midwifery curriculum toward SBA– 2 pathways identified• Midwifery technician (2 years)• BSC midwifery curriculum (4 years

• Gradual phasing out of old VMW curriculum in order not to affect coverage

• Road Map for Maternal and Child mortality reduction – Keys steps undertaken for operationalization -

detailing, costing and implementing the Road Map

• RH Communication strategy to guide all partners in implementing community interventions

Efforts and opportunities; Plans and strategies

Expanding access to effective child and maternity care

Efforts and opportunities; Plans and strategies

Graduation of VMWs by Years; Current coverage

52.4%

• ACSI Jump and pulse campaigns; Start in 15 States targeting 3.7 million U5s (Measles Vaccine, Polio Vaccine, Vitamin A, Iodine Tablets, De-worming, ITN and Health education massages

• Introduction of Penta-vaccine (DPT+HepB+Hib vaccine)

Expanding access to effective child and maternity care

Expanding access to effective child and maternity care

Rehabilitation of Hospitals and HCs Project

Expanding access to effective child and

maternity care

Expanding access to effective child and

maternity care

Rehabilitation of Hospitals and HCs Project

Expanding access to effective child and

maternity care • Central ambulance project; phase 1 (115

ambulances)

Increasing Political Commitment to Maternal and

Child Health-Higher Council for Child and

Maternal Mortality Reduction

• Ministerial decree• All partners in Health • State level councils -Wali decree (5 States)

Attracting External ResourcesUN agencies; WHO, UNFPA, UNICEF

GAVI Alliance

HMN

MDTF

GFATM

IDB

Bilateral relations; Chinese, Turkish and Japanese support

More coordination and focus on Health System issues is needed

Improving Quality of Services through Child and maternal death reviews

Recommendation of the Maternal Mortality

Reduction workshop – February 2007

The experience of Omdurman Maternity Hospital

Measures Taken to Reduce MMR in OMH:

• Mg SO4 and Hydralazine for severe pre-eclampsia and eclampsia

• Misoprostol for PPH

• Improvements in Blood Bank Services

• The use of thrombo-prophylaxis

• Audit meetings and quality control

Results of intervention (2003 – 7) in OMH

year Deliveries MD MMR

2003 18,462 40 216

2007 24,913 7 28

Effective interventions existThey need to reach more

people…..As we count down to

2015,

we need to strengthen health systems by unlocking the talent and resources that should be available to all mothers and

children….

In this forum, you are that talent….

Use your talent & knowledge to improve the quality of care that mothers and

children receive

By doing this, at the very least, you will honour those of Sudan who died earlier

than they should have

Thank you

THE REPUBLIC OF SUDAN

ECOSOC MEETING, GENEVIA6-10-2009