ROPOSAL ORM ROUND 8 (SINGLE COUNTRY APPLICANTS · ROUND 8 – Tuberculosis CP_CCM_R8_SUD_THSS_PF_23Sep08_En 2/94 INDEX OF SECTIONS and KEY ATTACHMENTS FOR PROPOSALS '+' = A key attachment

CP_CCM_R8_SUD_THSS_PF_23Sep08_En 1/94

PROPOSAL FORM – ROUND 8 (SINGLE COUNTRY APPLICANTS)

Applicant Name The Country Coordination Mechanism (CCM) northern Sudan

Country Sudan

Income Level (Refer to list of income levels by economy in Annex 1 to the Round 8 Guidelines)

Low income

Applicant Type CCM

Sub-CCM

Non-CCM

Round 8 Proposal Element(s):

Disease Title

HSS cross-cutting interventions

section (include in one disease only)

HIV1

Tuberculosis1 Addressing TB control in War affected, post conflict areas and other challenges.

Malaria

Currency USD or EURO

Deadline for submission of proposals: 12 noon, Local Geneva Time, Tuesday 1 July 2008 1 In contexts where HIV is driving the tuberculosis epidemic, applicants should include relevant HIV/TB collaborative

interventions in the HIV and/or tuberculosis proposals. Different HIV and tuberculosis activities are recommended for different epidemiological situations. For further information: see the ‘WHO Interim policy on collaborative TB/HIV activities’ available at: http://www.who.int/tb/publications/tbhiv_interim_policy/en/

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ROUND 8 – Tuberculosis


INDEX OF SECTIONS and KEY ATTACHMENTS FOR PROPOSALS

'+' = A key attachment to the proposal. These documents must be submitted with the completed Proposal Form. Other documents may also be attached by an applicant to support their program strategy (or strategies if more than one disease is applied for) and funding requests. Applicants identify these in the 'Checklists' at the end of s.2 and s.5.

1. Funding Summary and Contact Details 2. Applicant Summary (including eligibility) + Attachment C: Membership details of CCMs or Sub-CCMs Complete the following sections for each disease included in Round 8: 3. Proposal Summary 4. Program Description

4B. HSS cross-cutting interventions strategy ** 5. Funding Request

5B. HSS cross-cutting funding details **

** Only to be included in one disease in Round 8. Refer to the Round 8 Guidelines for detailed information.

+ Attachment A: 'Performance Framework' (Indicators and targets) + Attachment B: 'Preliminary List of Pharmaceutical and Health Products' + Detailed Work Plan: Quarterly for years 1 – 2, and annual details for years 3, 4 and 5 + Detailed Budget: Quarterly for years 1 – 2, and annual details for years 3, 4 and 5

IMPORTANT NOTE:

Applicants are strongly encouraged to read the Round 8 Guidelines fully before completing a Round 8 proposal. Applicants should continually refer to these Guidelines as they answer each section in the proposal form. All other Round 8 Documents are available here.

A number of recent Global Fund Board decisions have been reflected in the Round 8 Proposal Form. The Round 8 Guidelines explain these decisions in the order they apply to this Proposal Form. Information on these decisions is available at: http://www.theglobalfund.org/en/files/boardmeeting16/GF-BM16-Decisions.pdf. Since Round 7, efforts have been made to simplify the structure and remove duplication in the Round 8 Proposal Form. The Round 8 Guidelines therefore contain the majority of instructions and examples that will assist in the completion of the form.



1. FUNDING SUMMARY AND CONTACT DETAILS Clarified Table 1.1. 1.1. Funding summary

1.2. Contact details

Primary contact Secondary contact

Name Dr.Hashim Sulienman El Wagie Dr.Mustafa Salih

Title Manager Undersecretary assistant for Planning ,research and policies

Organization Sudan National Tuberculosis Programme

Federal Ministry of Health

Mailing address Khartoum P.O Box 303 Khartoum P.O Box 303

Telephone +249 9123 35717 +249 9121 63760

Fax +249 183 774212 +249 183 774212

E-mail address [email protected] [email protected]

Alternate e-mail address [email protected] [email protected]

Total funds requested over proposal term Disease

Year 1 Year 2 Year 3 Year 4 Year 5 Total

HIV

Tuberculosis 4,016,674 4,700,128 4,849,837 4,809,421 4,737,055 23,113,115

Malaria

HSS cross-cutting interventions within [Tuberculosis]

1,111,245 8,151,616 10,723,336 7,837,698 7,111,785 34,935,679

Total Round 8 Funding Request : 58,048,794



1.3. List of Abbreviations and Acronyms used by the Applicant

Acronym/ Abbreviation

Meaning

ACSM: Advocacy, Communication & Social mobilization ART: Anti Retroviral Therapy CDR: Case Detection Rate CMS: Central Medical Stores CRIS: Communication Resource Information DOTS: Directly Observed Treatment short course DRF: Drug Revolving Fund DRS: Drug Resistance Study DST: Drug Susceptibility Testing EMLs: Essential Medicines Lists Epi-lab: Epidemiological Lab FMOH: Federal Ministry of Health GFATM Round 5 grant GLC: Green Light Committee HRD: Human Resource Development IDPs: Internally Displaced Persons IEC: Information Education and Communication IUATLD: Internationl Union Agaisnt TB and Lung IWC: International Mother and Child Organization JPRM: Joint Planning and Review Meeting KAP: Knowledge Attitude and Practice LHL: Norwegian Lung and Heart Association M&E: Monitoring and Evaluation MDG: Millennium Development Goals MDR-TB Multi Drug Resistant TB MOU: Memorandum of Understanding NGOs: Non Governmental Organizations NHIS: National Health information system (). NRL: National Referral Laboratory OR: Operation Research PHC: Primary Health Care PLWHA People Living with HIV AIDS PPM: Public – Private Mix R5: GFATM Round 5 Grant SNTP: Sudan National TB Programme STGs: Standard Treatment Guidelines TA: Technical Assistance TBMU: TB Management Unit TOT: Training of Trainers TPA: TB Patient Association UNDP: UN Development Programme WHO: World Health Organization



2. APPLICANT SUMMARY (including eligibility)

IMPORTANT NOTE: Different from Round 7, ′income level′ eligibility is now set out in s.4.5.1 (focus on poor and key affected populations depending on income level), and in s.5.1. (cost sharing).

2.1. Members and operations

2.1.1. Membership summary

Sector Representation Number of members

Academic/educational sector 2

Government 9

Non-government organizations (NGOs)/community-based organizations 10

People living with the diseases 2

People representing key affected populations2

Private sector 1

Faith-based organizations 1

Multilateral and bilateral development partners in country 6

Other (please specify):

Total Number of Members:(Number must equal number of members in 'Attachment C''3)

32

2 Please use the Round 8 Guidelines definition of key affected populations. 3 Attachment C is where the CCM (or Sub-CCM) lists the names and other details of all current members. This

document is a mandatory attachment to an applicant's proposal. It is available at: http://www.theglobalfund.org/documents/rounds/8/AttachmentC_en.xls

CCM applicants: Only complete section 2.1. and 2.2. and DELETE sections 2.3. and 2.4.

Sub-CCM applicants: Complete sections 2.1. and 2.2. and 2.3. and DELETE section 2.4.

Non-CCM applicants: Only complete section 2.4. and DELETE sections 2.1. and 2.2. and 2.3.

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2.1.2. Broad and inclusive membership

Since the last time you applied to the Global Fund (and were determined compliant with the minimum requirements):

(a) Have non-government sector members (including any new members since the last application) continued to be transparently selected by their own sector; and

No Yes

(b) Is there continuing active membership of people living with and/or affected by the diseases. No Yes



2.1.3. Member knowledge and experience in cross-cutting issues

Health Systems Strengthening

The Global Fund recognizes that weaknesses in the health system can constrain efforts to respond to the three diseases. We therefore encourage members to involve people (from both the government and non-government) who have a focus on the health system in the work of the CCM or Sub-CCM.

(a) Describe the capacity and experience of the CCM (or Sub-CCM) to consider how health system issues impact programs and outcomes for the three diseases.

The representation in CCM Sudan northern sector generally included higher officials from different organizations working in health sector. In CCM sub-organizations the specialized Health System Subcommittee was formulated early in 2007 that include the key officials in the health system components especially in the ministry of health including; DG of Planning & Health Development Directorate, DG of Health System Support Department, DG of Training & Human Recourses for Health Directorate in addition to the diseases programs directors; and this to more deliberating the crosscutting issues regarding the health system for the diseases control plans including the development of management policies.

Gender awareness

The Global Fund recognizes that inequality between males and females, and the situation of sexual minorities are important drivers of epidemics, and that experience in programming requires knowledge and skills in:

methodologies to assess gender differentials in disease burdens and their consequences (including differences between men and women, boys and girls), and in access to and the utilization of prevention, treatment, care and support programs; and

the factors that make women and girls and sexual minorities vulnerable.

(b) Describe the capacity and experience of the CCM (or Sub-CCM) in gender issues including the number of members with requisite knowledge and skills.

CCM Sudan northern sector since its establishment in 2002 consider the gender issue into consideration and within the membership of CCM the head of Woman Association for AIDS Prevention was representing this sector.

In addition to that the memberships of CCM Sudan northern sector include higher representation from the relevant UN agencies including UNICEF country representative and UNFPA-HIV/AIDS national coordinator.

Multi-sectoral planning

The Global Fund recognizes that multi-sectoral planning is important to expanding country capacity to respond to the three diseases.

(c) Describe the capacity and experience of the CCM (or Sub-CCM) in multi-sectoral program design.

Since its establishment the CCM Sudan northern sector consists of planning bodies as disease based entities. These were formulated as CCM subcommittees for HIV/AIDS, TB & Malaria that each subcommittee involves representation from different organizations from different sectors.

The main role of these subcommittees is to take the applicable decisions regarding the implementation of all disease grant(s) supported by the Global Fund and this is done within the routine monthly meetings of these entities that discuss the previous implementation and potential plans then it recommend to the CCM common meeting regarding its oversight role.

This mechanism considerably improves the capacity of CCM in Sudan regarding the support of National programs for the three diseases.



2.2. Eligibility

2.2.1. Application history

'Check' one box in the table below and then follow the further instructions for that box in the right hand column.

Applied for funding in Round 6 and/or Round 7 and was determined as having met the minimum eligibility requirements.

Complete all of sections 2.2.2 to 2.2.8 below.

Last time applied for funding was before Round 6 or was determined non-compliant with the minimum eligibility requirements when last applied.

First, go to ′Attachment D′ to and complete. (Do not complete sections 2.2.2 to 2.2.4)

Then also complete sections 2.2.5 to 2.2.8 below.

2.2.2. Transparent proposal development processes Refer to the document 'Clarifications on CCM Minimum Requirements' when completing these questions.

Documents supporting the information provided below must be submitted with the proposal as clearly named and numbered annexes. Refer to the ′Checklist′ after s.2.

(a) Describe the process(es) used to invite submissions for possible integration into the proposal from a broad range of stakeholders including civil society and the private sector, and at the national, sub-national and community levels. (If a different process was used for each disease, explain each process.)

In the process to develop the proposal of CCM Sudan to the Global Fund for Round 8 was highly improved through different measures and process taken place.

The key reference to this process was the developed CCM Standard Operating Procedures “SOP Manual” attached as annex 1 (CCM SOP Manual) that describe in details the steps to be taken to develop, review and submit any potential CCM proposal to the Global Fund.

1. The CCM decided in its meeting 13/01/2008 o apply for R8 following the opening call for proposals by the Global Fund and this was based on the recommendations from TB Subcommittee, attached minutes as annex 2 (CCM Meeting on 13/01/2008).

2. CCM Sudan Secretariat announced the opening of call for proposals integration for TB & HSS components for R8 through the official website (www.fmoh.gov.sd/ccm) and how the potential contributions could be directed, attached as annex 3 (CCM call for concept papers).

3. TB CCM Subcommittee in its meeting conducted to inform the partners that CCM will start to develop the proposal for Round 8 include TB component in addition to HSS component.

4. Upon the recommendations CCM chairman formulate two Technical Working Groups for each component considering the participation of different experts from different relevant organizations for each component to make sure that all potential integrations in the proposal development could be considered especially in TB component, attached as CCM Chairman decision annex 4 (TWG Formulation Decision).

(b) Describe the process(es) used to transparently review the submissions received for possible integration into this proposal. (If a different process was used for each disease, explain each process.)


1. Any written suggestions that are received by the TWGs from any organizations (or persons weather are CCM members or not CCM members) regarding any possible integration into the proposal was considered during the proposal development process and the TWGs informed CCM



Secretariat by these suggestions in written.

2. Before it was included in the proposals these suggestions was revised and adjusted according to the proposal outlines and TWGs and CCM Secretariat provide feedback the organizations offer its integration by the decision of the CCM.

(c) Describe the process(es) used to ensure the input of people and stakeholders other than CCM (or Sub-CCM) members in the proposal development process. (If a different process was used for each disease, explain each process.)


1. After the TWG complete the general discussions and outlining the proposal headlines it was presented in the CCM meeting dated on 21/05/2008 as a progress update for the proposal development for the 2 components, attached as annex 5 (CCM Meeting on 21/05/2008).

2. The circulation of the first draft of the proposal component for HSS was on 15/06/2008 and for TB component was on 18/06/2008 and CCM Secretariat asked the stakeholders to communicate directly with TWGs principals for any potential inputs or contribution.

3. The final draft of the proposal for both component was circulated on 23/06/2008 to all CCM members and non members involved in the process before the endorsement meeting of the CCM which was conducted on 25th June 2008, attached as annex 6 (CCM Meeting on 25/06/08).

(d) Attach a signed and dated version of the minutes of the meeting(s) at which the members decided on the elements to be included in the proposal for all diseases applied for.

[Annex 6 CCM Meeting on 21/05/2008]

2.2.3. Processes to oversee program implementation

(a) Describe the process(es) used by the CCM (or Sub-CCM) to oversee program implementation.

As it was described in the detailed proposal the PR will be fully responsible for program implementation. The PR will follow the implementation through the development of gr. The unit will review the implementation through meetings, field visits and evaluation of grant management plan with under the supervision of the CCM. The PR is doing that under the guidance of GFATM and the governance of CCM as it is clearly detailed in the CCM Manual, attached as annex 7 (CCM Manual).

(b) Describe the process(es) used to ensure the input of stakeholders other than CCM (or Sub-CCM) members in the ongoing oversight of program implementation.

The following processes now were implemented to ensure that the implementation was monitored under the supervision of CCM and under transparent processes:

1. Principal Recipient progress Updates were distributed electronically to all stakeholders using CCM web date-base on quarterly basis.

2. Principal Recipient disbursement reports were distributed electronically to all stakeholders using CCM web date-base on 6 months basis.

3. Principal Recipient Fiscal Year Progress Report was distributed electronically to all stakeholders using CCM web date-base on 12 months basis.

CCM Secretariat was sharing all of these reports with stakeholders in regular basis, should any partner(s) have any comment it was usually discussed within the CCM common meeting. Otherwise the partners could communicate with the PR directly or through the CCM secretariat



2.2.4. Processes to select Principal Recipients

The Global Fund recommends that applicants select both government and non-government sector Principal Recipients to manage program implementation. Refer to the Round 8 Guidelines for further explanation of the principles. .

(a) Describe the process used to make a transparent and documented selection of each of the Principal Recipient(s) nominated in this proposal. (If a different process was used for each disease, explain each process.)

The key reference to this process was the developed CCM Standard Operating Procedures “SOP Manual” attached as annex 1 (CCM SOP Manual) that describe in details the steps to be taken to nominate and determine the principal recipient.

1. In the final drat of the proposal the TWGs and subcommittees decided which organization that the recommend to the CCM to be selected as PR, in this grant the TWG recommend UNDP as PR.

2. CCM circulate the final draft on 23/06/2008 to all stakeholders involved in the proposal development process.

3. In the endorsement meeting conducted on 25/06/2008 the CCM chairman ask the members for their approval for the recommendations of the TWGs and SCs and upon discussions the PR was determined based on that, attached as annex 6 (CCM Meeting on 25/06/08).

(b) Attach the signed and dated minutes of the meeting(s) at which the members decided on the Principal Recipient(s) for each disease.

[Annex 6 (CCM Meeting on 25/06/08]

2.2.5. Principal Recipient(s)

Name Disease Sector**

United Nation Development Program Sudan Tuberculosis Multilateral and bilateral development partners in country

[use "Tab" key to add extra rows if needed]

** Choose a 'sector' from the possible options that are included in this Proposal Form at s.2.1.1.

2.2.6. Non-implementation of dual track financing

Provide an explanation below if at least one government sector and one non-government sector Principal Recipient have not been nominated for each disease in this proposal.

Not applicable

2.2.7. Managing conflicts of interest

Yes provide details below (a) Are the Chair and/or Vice-Chair of the CCM (or Sub-CCM) from the

same entity as any of the nominated Principal Recipient(s) for any of the diseases in this proposal?

No



go to s.2.2.8.

(b) If yes, attach the plan for the management of actual and potential conflicts of interest.

Yes [Insert Annex Number]

2.2.8. Proposal endorsement by members

Attachment C – Membership information and Signatures

Has 'Attachment C' been completed with the signatures of all members of the CCM (or Sub-CCM)? Yes

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3. PROPOSAL SUMMARY

3.1. Duration of Proposal Planned Start Date To

Month and year:

(up to 5 years) January 2009 December 2013

3.2. Consolidation of grants Yes

(go first to (b) below) (a) Does the CCM (or Sub-CCM) wish to consolidate any existing

tuberculosis Global Fund grant(s) with the Round 8 tuberculosis proposal? No

(go to s.3.3. below)

‘Consolidation’ refers to the situation where multiple grants can be combined to form one grant. Under Global Fund policy, this is possible if the same Principal Recipient (‘PR’) is already managing at least one grant for the same disease. A proposal with more than one nominated PR may seek to consolidate part of the Round 8 proposal.

More detailed information on grant consolidation (including analysis of some of the benefits and areas to consider is available at: http://www.theglobalfund.org/en/apply/call8/other/#5

(b) If yes, which grants are planned to be consolidated with the Round 8 proposal after Board approval? (List the relevant grant number(s))

3.3. Alignment of planning and fiscal cycles

Describe how the start date:

(a) contributes to alignment with the national planning, budgeting and fiscal cycle; and/or

(b) in grant consolidation cases, increases alignment of planning, implementation and reporting efforts.

This project is planned to start in January 2009 which is the starting month of the fiscal year of the government and is in line with the commencement of national planning and budgeting. It is also in line with National TB Program cycles. Additionally, most NGOs and sub-recipients start planning and budgeting in January. Thus project commencement will harmonize with the existing program, facilitate the smooth progress of reporting and the financial procedures, as well as the flow of domestic budgetary allocations required to be released for the SNTP.

3.4. Program-based approach for Tuberculosis

Yes. Answer s.3.4.2 3.4.1. Does planning and funding for the country's response to tuberculosis occur through a program-based approach?

No. Go to s.3.5.

3.4.2. If yes, does this proposal plan for some or all of the requested funding to be paid into a common-funding mechanism to support that approach?

Yes Complete s.5.5 as an additional section to explain the financial operations of the common funding mechanism.



No. Do not complete s.5.5



3.5. Summary of Round 8 Tuberculosis Proposal

Provide a summary of the tuberculosis proposal described in detail in section 4.

NTP adopted DOTS as national strategy in 1994 and, together with partners, has worked for DOTS scale. GFATM R5 support which started in 2005 has particularly been instrumental because it has supported provision of TB drugs and lab supplies, supervision, M/E and training. As a result, there are around 300 TB MU in Sudan, covering in average 100,000 population per TBMU. A total of 29,019 TB patients were notified in 2006. Treatment success rate was 82%. Still, Tuberculosis is a public health emergency in Sudan. The estimated prevalence of TB is very high at 419 per 100,000 populations. TB affects 158,115 people every year in Sudan. HIV/AIDS is in generalized epidemic and 4-6% of TB patients are HIV sero-positive. The long standing conflict and complex emergency situation has negatively affected TB care and epidemiological pattern in Sudan. There are 3 main gaps behind this emergency. One is TB care in ongoing conflict and war areas, particularly in Darfur. Second is quality of DOTS, in particular laboratory and M/E. Third is incomplete TB care for other important areas like MDR-care, PPM and ACSM: HIV/TB and OR were also important but are largely addressed with the current GF support including one for HIV/AIDS. Without addressing these gaps, Sudan may not be able to put TB under real control. At the same time, the R8 proposal will maintain the critical activities supported by R5 grant support once the R5 grant will end on 2010. The activities include: HRD including support for supervision, performance-based incentives and technical assistance, and provision of first line TB drugs. R8 will support such activities from 2011 which is Year 3 of R8 Proposal. The overall goal of the Project is to drastically reduce the TB burden in Sudan, particularly among poor and vulnerable populations in line with the 2015 MDG and the Stop TB Partnership targets. The Proposal will have five objectives: (1) Expand DOTS in war-affected areas particularly in Darfur and other States; (2) Pursue high-quality DOTS; (3) Address MDR-TB care & contact management; (4) engage all health care providers, and (5) Advocacy, Communication & Social mobilization. The first and second objectives are to respond to the first and second gaps mentioned above, and the third to fifth objectives are for the third gap mentioned the above. Objective 1: Expand DOTS, especially in war-affected areas in the Western region (Darfur States) Access to TB care is limited in the conflict and war affected areas in Sudan, particularly in Darfur in Western Region. There are probably around 3 million displaced and refugee populations in Sudan. The Proposal aims at improving access to TB care in these areas through brining all partners particularly NGOs in the field and scaling up DOTS in collaboration with these partners. Objective 2: PURUSE HIGH QUALITY DOTS SERVICES While DOTS is expanded in Sudan to having around 300 TBMU, quality of DOTS is not at the optimal level. This is particularly relevant to laboratory and M/E. The proposal will assist the strengthening of network of quality assured laboratories by renovating 105 laboratories, establishing 5 zonal culture laboratories, and equipping the NRL for DRS. Close supervision, monitoring and evaluation will be also enhanced, including external quality assurance. Support for computerized surveillance system will also be provided.



Objective 3: Prevent and control MDR-TB, and address TB contact management: This objective aims at establishing baseline information on MDR TB in Sudan and MDR TB care In collaboration with NRL, SNTP will conduct an MDR survey, and introduce MDR care based on WHO/GLC recommendations. The proposal will also assist the work with one hospital, where treatment of MDR TB patients will commence. MDR surveillance will also be conducted. Objective 3: Engage all health care providers - Strengthen PPM approaches: This objective aims at expanding PPM with public and private sector so as to increase TB case detection. Building on Round 5, SNTP will partner with a number of public health facilities to provide TB care services. SNTP will also partner with private health care providers, starting with a pilot program involving 20 private clinics in Khartoum State and 10 private clinics in Gezira state to introduce innovative performance-based incentive system. Expansion will be carried out after evaluation of the pilot phase. Objective 4: Advocacy, Communication & Social Mobilization: Raise TB awareness, build knowledge and create positive perceptions toward TB prevention, treatment efficacy and adherence, and reduce stigmatizing attitudes: This objective aims to expand on the ACSM achievements from R5. A more strategic, integrated, multilevel programming approach is proposed to achieve measurable behavioural impact. In order to expand on the community reach of the program, more stakeholders operating within existing networks will be engaged in program activities. Most important is the need to raise awareness, build knowledge and empower marginalized groups through targeted interventions in war affected and post conflict areas. The requested fund for the Proposal is USD 20,632,757 for 5 years: USD 8,657,803 for the first 2 years. The Proposal aims at increasing case detection from 36% to 75% in five years while improving treatment success from 82% to 87%. The Proposal eventually aims at achieving 70% case detection rate in Year 3 & 75% in Year 5. By achieving this, the Proposal is expected to contribute to detecting a total of around 553404 TB patients which include 333204 smear positive TB cases in 5 years. NB: The executive summary for health system strengthening is added as Annex 12-Executiev Summary-HSS



4. PROGRAM DESCRIPTION

4.1. National program and strategy

(a) Briefly summarize:

the current tuberculosis national program or strategy;

how the strategy responds comprehensively to current epidemiological situation in the country; and

The improved tuberculosis outcomes expected from implementation of these program or strategy.

The current national tuberculosis program is being implemented by the Federal Ministry of Health with other partners. The overall Sudan NTP (SNTP) vision is a Sudan free of TB (TB_strategic_Final_25_3_2007, Annex 1). To help achieve this vision, the SNTP have the following mission:

Stop TB transmission by implementing effective preventive and control strategies to eliminate TB.

Ensure that every patient has equal access to effective diagnosis, treatment, follow up and cure.

Reduce the social and economic impact of TB at the family and community level. The goal of SNTP is to reduce the prevalence and mortality from tuberculosis by 50% by 2015. Sudan carries 8-11% of the TB burden in the Eastern Mediterranean Region (EMR), and is second to Pakistan in terms of the number of TB patients. In 2006, the estimated incidence of new smear-positive TB cases was 108 per 100 thousand population, translating to almost 41,000 new smear-positive cases. Prevalence of all forms of TB is 419 per 100,000 population or 158,000 cases.4 DOTS is a national strategy for TB care in Sudan. NTP adopted DOTS in 1994, and started with pilot projects. Diagnosis is based on the sputum examination of TB susptects. Treatment is standardized with 8-month Category 1, 2 and 3 regimens. WHO recommended recording and reporting system is in place. NTP has three levels of organizations: Central unit in Khartoum; state TB and laboratory coordinators in all 15 states, and TBMU. At present, there are around 300 TBMU in Sudan, covering in average 100,000 populations. TBMU is staffed with a medical officer, laboratory officer and stastician, and equipped with miscroscopy laboratory. Each TBMU has at least 3 DOTS centers for treatment under DOT. Because of the ongoing conflicts like those in Darfur;Abeye and South Kordifan, many TBMUs in conflit areas are not always functional. In 2006, out of estimated 41,000 total smear positive cases, only about 12,000 were notified to the SNTP; a case detection rate of 32% and far below the global target of 70%. This low case detection is particularly a problem war-affected and post-conflict areas . While Khartoum and the Red Sea states have achieved a 70% detection rate, in the war-affected and post-conflict states, case detectionrate (based on notification for 2006) is extremely low: CDR for North Darfur was 23%, West Kordofan 12%, South Darfur 3%, and West Darfur 2%. These states account for 22.4% of the total Sudanese population, but contribute only to 4% of the total case notification in the country. These data clearly demonstrate an underlying problem in the distribution and accessibility of communities to TB care services. At the same time, a treatment success rate of 82% was achieved among the small proportion detected. 5 This is a good achievement. However, the defaulter rate remains high with an

4 Global tuberculosis control: surveillance, planning, financing: WHO report 2008. 5 Treatment Outcome report, 2005 cohort.



average default rate of 9%, particulalry in areas that are affected by the civil war and conflicts in Darfur and the Eastern parts of the country. In these areas, provision of all government health services, including TB services have been seriously afected. The concentration of health care provider activities in these zones has been drawn towards treating acute illnesses, with a resultant reduction in TB control activities. In terms of MDR prevalence, the prevalence of MDR-TB in new smear-positive TB cases was estimated at 10.1%.6 However, no national survey on MDR has been carried out to date. In an effort to follow up on MDR-TB, the SNTP established a national TB Reference Laboratory in 2003, in collaboration with Epi-lab and the National Health Laboratory (NHL), with support from LHL, IUATLD and FMOH. The laboratory is capable of peforming culture, and by the end of 2008 the laboratory will also be able to perform DST. After commencing a pilot study for MDR-TB in Khartoum State, the SNTP, in collaboration with its partners, is planning to conduct a nation-wide MDR-TB survey in 2009. The current strategic plan addresses the expansion and enhancement of quality DOTS, TB/HIV, prevention and control of MDR-TB, childhood TB, and empowerment of people with TB and communities, as priority areas for the period 2006-2010. The ongoing conflicts have caused displacement of populations thus making access to TB services difficult. For these reasons, the proposed strategy to expand DOTS in the war-affected and post conflict areas can only be achieved through establishing effective partnerships with national and international NGOs currently delivering health services to IDPs. The strategic plan also emphasizes the need to improve the laboratory network and services, and upgrading of the existing monitoring and supervisory system at different levels to meet the planned expansion. Staff training at different levels, development and operationalisation of TB service standards are aimed at improving the quality of services. Other strategic approaches planned include advocacy to improve political commitment to increase funding at federal and state levels. Enhanced ACSM and building of community partnerships for DOTS implementation will also be emphasised to improve case detection and reduce defaulter rates. Activities to reduce the serious economic burden on families affected by TB are also identified in this proposal.

(b) From the list below, attach* only those documents that are directly relevant to the focus of this proposal (or, *identify the specific Annex number from a Round 7 proposal when the document was last submitted, and the Global Fund will obtain this document from our Round 7 files).

Also identify the specific page(s) (in these documents) that support the descriptions in s.4.1. above.

Document Proposal Annex

Number Page References

National Health Sector Development/Strategic Plan 4

National Tuberculosis Control Mid Term Strategy or Plan 1

National Tuberculosis Guidelines (medical and laboratory) 3

Important sub-sector policies that are relevant to the proposal (e.g., national or sub-national human resources policy, or norms and standards)

6 WHO –HTM –TB – 2008. 394.

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Most recent annual reports, monitoring mission reports or reviews, including any epidemiology report directly relevant to the proposal

2

National Monitoring and Evaluation Plan (health sector, disease specific or other)

5

National policies to achieve gender equality in regard to the provision of tuberculosis diagnosis, treatment, and care and support services to all people in need of services

4.2. Epidemiological Background

4.2.1. Geographic reach of this proposal

(a) Do the activities target:

X Whole country

Specific Region(s)

**If so, insert a map to show where

Specific population groups **If so, insert a map to show where these groups are if they are in a specific area of the country

** Paste map here if relevant

(b) Size of population group(s) targeted in Round 8

Population Groups Population Size Source of Data Year of Estimate

Total country population (all ages) 35,397,000 Central Bureau of Statistics 2005

Women > 25 years 8,411 Central Bureau of Statistics 2005

Women 19 – 24 years 3,651 Central Bureau of Statistics 2005

Women 15 – 18 years 1,952 Central Bureau of Statistics 2005

Men > 25 years 6,504 Central Bureau of Statistics 2005

Men 19 – 24 years 3,849 Central Bureau of Statistics 2005

Men 15 – 18 years 2,036 Central Bureau of Statistics 2005

Girls 0 – 14 years 7,204 Central Bureau of Statistics 2005

Boys 0 – 14 years 7,488 Central Bureau of Statistics 2005

Other **: Internally displaced populations 2,846,976 WHO, UN 2008

Other **: Refugees 140,000 WHO 2008

Other **:

r



(b) Size of population group(s) targeted in Round 8

Population Groups Population Size Source of Data Year of Estimate

Clarified Table 4.2.2.

4.2.2 Tuberculosis epidemiology of target population(s)

Population Groups Number Source of Data Year of Estimate

Estimated tuberculosis patients - shown as number per 100,000 population (all ages)

28,460 SS+ 56,920 all

forms SNTP 2007

Female tuberculosis patients > 25 years 2,965 SNTP 2007 Female tuberculosis patients 19 – 24 years 736

SNTP 2007

Female tuberculosis patients 15 – 18 years Na

SNTP

Male tuberculosis patients > 25 years 5,644 SNTP 2007 Male tuberculosis patients 19 – 24 years 1,126 SNTP 2007 Male tuberculosis patients 15 – 18 years Na Notified Tuberculosis patients all forms (shown as number per 100,000 population)

23,895 SNTP 2007

Tuberculosis patients all forms tested for HIV (rate among notified 201 SNTP 2007 Estimated number new smear-positive tuberculosis patients (rate per 100,000 habitants)

28,460 SNTP 2007

Notified new smear-positive tuberculosis patients (rate per 100,000 habitants)

9,982 SNTP 2007

Case detection rate of new smear-positive cases 35.1 SNTP 2007 Estimated number of multi-drug resistant cases of tuberculosis 1696

Anti tuberculosis drug resistance in the world7

2007

Notified number of multi-drug resistant cases bacteriologically confirmed

61 NRL 2006

Treatment success rate of new smear-positive cases 81.1 SNTP 2006 Defaulter and transfer rate of new smear-positive cases

Defaulter=806 Transfer=255 SNTP 2006

Estimated number of girl (0 – 14 years) tuberculosis patients all forms

13,478 SNTP 2005

Notified number of girl (0 – 14 years) tuberculosis patients all forms

340 SNTP 2005

Estimated number of boy (0-14 years) tuberculosis patients all forms

12,967 SNTP 2005

7 WHO –HTM –TB – 2008. 394.



4.2.2 Tuberculosis epidemiology of target population(s)

Population Groups Number Source of Data Year of Estimate

Notified number of boy (0 – 14 years) tuberculosis patients all forms

388 SNTP 2005

Other**: Internally displaced populations - The data is not available -

Other**: Refugees - The data is not available -

4.3. Major constraints and gaps

4.3.1. Tuberculosis program

Describe: the main weaknesses in the implementation of current tuberculosis program or strategy; how these weaknesses affect achievement of planned national tuberculosis outcomes; and existing gaps in the delivery of services to target populations. While the GF R5 support has contributed to scale up of TB control, particularly DOTS in Sudan, TB remains a public health emergency. The prevalence of TB is very high and case detection rate is still very low at 32%, although treatment success rates are high at 82%. There are many challenges that have directly and indirectly resulted in the TB emergency. However, there are three major constraints in TB care in Sudan. First is TB care in ongoing, if not worsening, conflict and war areas particularly in Darfur in Western Region. There are probably around 3 million displaced and refugee populations in Sudan. This includes around 2.8 million IDP (Darfur States: 2.5 million, Blue Nile State: 35 thousand South Kordofan State: 190,000, and Eastern states: 170,000), and around 140,000 refugees in Eastern States. Approximately 70-80% of all refugees and IDPs are women and Children. There is limited support to expand DOTS services in these areas. Displaced people and slum dwellers who are poor and marginalized, are at highest risk of contracting TB. Populations in the war affected and post conflict areas, and slums currently have little or no access to TB services. Some health facilities were destroyed during the conflict, and are still yet to be fully functional thus weakening service delivery. For example, case detection rate in the war affected areas is even lower in; North Darfur (23%), Western Kordofan (12%), South Darfur (3%) and Western Darfur (2%) states. Despite these states comprising 22.4% of the total population, they only account for 4% of the national case notification. Without improved access to TB care, prevalence of TB will remain high and SNTP will face huge challenge to bring TB under real control. The second gap is the quality of DOTS. The Third gap is incomplete implementation of Stop TB Strategy. MDR The magnitude of the MDR in the country is unknown. There is no baseline information and



the estimated MDR TB rate of 10.1% in Sudan is based on project epidemiological observation. There are no guidelines on operation plan for MDR TB. The second main gap is lack of MDR-TB management services. Establishing baseline information and data, as well as development of operational guidelines, will help in the management of the MDR-TB. PPM The public health sector is the biggest health care provider in the country. R5 provided funding for the public – public mix (PPM) and some activities are being implemented, but only to a small proportion of this sector. In order to increase case detection, greater efforts are needed to engage the public sector. The private health care sector also constitutes a significant proportion of health services delivery and a recent assessment indicates that there are 229 private hospitals and health centers in Sudan.8 Current PPM activities do not cover the private sector. Therefore, the third main gap is inadequate involvement of other health care providers. In order to increase case detection it is important to expand the public-public partnerships with SNTP and also involve the private sector in TB care services. ACSM Community awareness and empowerment is critical to the long term success of TB control programs. ACSM influences health seeking behaviour, especially where TB stigmatizing attitudes create barriers to patient compliance. The ACSM component of the program is weak and therefore, the potential for improved case detection and reductions in treatment adherence is reduced. While minimal ACSM activities have been supported by R5, awareness activities have been conducted in very few TBMUs. Additionally, there is neither ACSM strategy nor operational plan. As a result of these weaknesses community participation is minimal. Therefore, the fourth main gap is limited community awareness/mobilization and involvement in TB care. TB/HIV – is a big problem but is reasonably addressed with GF HIV/AIDS support to Sudan OR – is a gap but addressed by GF R5 TB. TB/HIV - is a big gap, but will be addressed with GF HIV/AIDS support to Sudan. In summary, the main gaps are:

Limited TB care services for the people in conflict and war‐affected areas in particular Darfur

Lack of MDR‐TB management services.

Inadequate involvement of other health care providers.

Limited community awareness/mobilization

4.3.2. Health System Describe the main weaknesses of and/or gaps in the health system that affect tuberculosis outcomes. The description can include discussion of: issues that are common to HIV, tuberculosis and malaria programming and service delivery; and issues that are relevant to the health system and tuberculosis outcomes (e.g.: PAL services), but

perhaps not also malaria and tuberculosis programming and service delivery. The health system in Sudan is comprised of two main sectors; public and private. In the public sector, the main health care provider is the Federal Ministry of Health (FMOH) which is responsible for providing health care to the entire population (about 37 million). The country is a decentralized federation with three administrative levels, Federal, State and Locality levels. There are 357 hospitals, 1,016 health centres (558 urban and 458 rural), 1,226 dispensaries, 762 dressing stations and 3,044 PHC units. Sudan has suffered from protracted conflicts and the country is in a chronic emergency situation. This has affected the health sector negatively including TB health care. Darfur states have been the most affected with conflicts still ongoing. In the post-conflict states of South

8 FMOH Health Centre Study 2008 (unpublished report).



Kordofan, Blue Nile and Eastern states the effects of war have also seriously damaged health care services. It is estimated that in these states 2 million persons are internally displaced. More than 60 % of health facilities need rehabilitation in Darfur and the post conflict zones. TB service delivery is integrated in most public health facilities and thus factors affecting the health sector, also affect TB service delivery. Some of the main weaknesses and gaps are described below. Health Service delivery The FMOH has health development plans to improve health service delivery including rehabilitation and renovation of health infrastructure, capacity building and improving skills of health personnel, design of strategic health plans and the provision of support to strengthen the health system. However, the capacity to deliver adequate health services have been severely affected by prolonged conflicts and instability. The current situation indicates that FMOH will not, in the near future, be able provide sufficient resources to deliver health services including TB care, especially to the poor and vulnerable groups. TB control is a priority of FMOH but its capacity is limited and it is unable to deliver all the needed care. Though overall access to PHC is estimated 45-65%, the health facilities are un-evenly distributed and about 29% of these PHC facilities are not functional. The prolonged conflicts coupled with poor infrastructure, have seriously affected health services, especially in the war affected and post conflict areas. Some health facilities are inaccessible, while some have completely stopped providing services. The situation in stable areas is not very different as the conflicts have affected the entire country. The slums in and around urban centres have been growing steadily and the health system is not able to cope with this increasing demand. Human Resource: The current human resource in the health sector is inadequate due to a brain drain to overseas countries. Available health staff are inequitably distributed with rural areas and especially war affected areas suffering most. Refresher and in-service training is inadequate. Incentives and salaries are insufficient, and there is a high turnover of human resources. Health Financing: Generally the health sector, including SNTP is under-funded at all levels due to chronic budgetary constraints. The data on health financing and expenditure is deficient and incomplete. With an increase in oil revenues, allocation to the health sector has also increased, but it is still far from being able to make a significant impact on the health budget with the budget biased towards secondary and tertiary health care. Governance and Leadership: While the FMOH has policies and strategies in place, the capacity of management systems to implement these strategies and policies in the decentralized system is limited. Coordination, supervision, and M&E are inadequate. Managerial and technical capacities are weak. National Health Information System: The NHIS is weak and there is low capacity to manage health information and data, especially at state and locality levels. SNTP surveillance is not integrated within the National Health information system (NHIS).

4.3.3. Efforts to resolve health system weaknesses and gaps Describe what is being done, and by whom, to respond to health system weaknesses and gaps that affect tuberculosis outcomes. International assistance to the health sector in the past decade has not been significant. The donor inputs for health through FMOH in the year 2002 amounted to US$20 million, which comes to US60 cents per person. The allocated budgets for NGOs working in Sudan is estimated at US$41 million in 2002. Donor inputs generally focus on control of communicable diseases (Vaccine preventable diseases, Malaria/TB/Leprosy control, HIV/AIDS, Guinea Worm control and control of river blindness). The health sector has suffered a lot during the last two decades, and especially following the last war in Darfur. About 60 % of health facilities need to



be rehabilitated due to ongoing conflict in Darfur and other zones. Although, the government has rehabilitated a few centers, the overall quality of services provided are still poor and below public expectations due to poor infrastructure, inadequate human resources and poor financial support. Moreover, there is inequality and mal-distribution of health care. Although the current health system has become more fragile, it is still able to provide basic support to many TB patients. The majority of the governorate PHC clinics are still functioning, and providing essential diagnostic and therapeutic services to the community. Accordingly the structure and human resources are available to allow the scaling up of TB care. However, the gaps are becoming increasingly large, particularly with regard to care for vulnerable and poor populations, and it is becoming extremely difficult to improve the existing services with currently available resources. The FMOH has health development plans, which are a part of the national development plan for Sudan. These plans include rehabilitation and renovation of health infrastructure, building capacity and skills of health personnel, designing strategic plans in the longer term to ensure the participation of the private health sector and the community, to provide support to strengthen the health system. The current and the immediate future emergency situation in the country will not allow the FMOH to provide sufficient resources to tackle the problem of inadequate TB care for poor and vulnerable groups, and to ensure provision of acceptable quality of care to all TB patients. The resources available through GFATM can be utilized in rising managerial and technical capacity, improving infrastructure, improving the availability, access, and utilization of TB care, and enhancing TB social mobilization in Sudan.



4.4. Round 8 Priorities

Complete the tables below on a program coverage basis (and not financial data) for three to six areas identified by the applicant as priority interventions for this proposal. Ensure that the choice of priorities is consistent with the current tuberculosis epidemiology and identified weaknesses and gaps from s.4.2.2 and 4.3.

Note: All health systems strengthening needs that are most effectively responded to on an tuberculosis disease program basis, and which are important areas of work in this proposal, should also be included here.

Priority No: 1

High quality DOTS expansion Historical Current Country targets

Intervention Establish TBMUs in war affected areas

2006 2007 2008 2009 2010 2011 2012 2013

A: Country target (from annual plans where these exist) 5 2 2 10 15 20 25 30 B: Extent of need already planned to be met under other programs 1 1 1 1 1 1 1 1

C: Expected annual gap in achieving plans 9 14 19 14 29 D: Round 8 proposal contribution to total need (e.g., can be equal to or less than full gap) 9 14 19 14 29

Priority No: 2 MDR-TB and other challenges Historical Current Country targets

Intervention No of TB pt receiving 2nd line drugs 2006 2007 2008 2009 2010 2011 2012 2013

A: Country target (from annual plans where these exist) 0 0 0 80 120 150 170 180 B: Extent of need already planned to be met under other programs 0 0 0 0 0 0 0 0

C: Expected annual gap in achieving plans 80 120 150 170 180 D: Round 8 proposal contribution to total need (e.g., can be equal to or less than full gap) 80 120 150



Priority No:3

Empowerment of people with TB and communities - Community TB Care

Historical Current Country targets

Intervention Train Community DOTS volunteers

2006 2007 2008 2009 2010 2011 2012 2013

A: Country target (from annual plans where these exist) 0 0 0 250 250 200 200 B: Extent of need already planned to be met under other programs 0 0 0 0 0 0 0

C: Expected annual gap in achieving plans 0 0 0 250 250 200 200

D: Round 8 proposal contribution to total need (i.e., can be equal to or less than full gap) 250 250 250 200

Priority No:4

Historical Current Country targets

Intervention 2006 2007 2008 2009 2010 2011 2012 2013

A: Country target (from annual plans where these exist) B: Extent of need already planned to be met under other programs

C: Expected annual gap in achieving plans D: Round 8 proposal contribution to total need (i.e., can be equal to or less than full gap)

If there are six priority areas, copy the table above once more.



4.5. Implementation strategy

4.5.1. Round 8 interventions Explain: (i) who will be undertaking each area of activity (which Principal Recipient, which Sub-Recipient or other implementer); and (ii) the targeted population(s). Ensure that the explanation follows the order of each objective, program work area (or, "service delivery area (SDA)"), and indicator in the 'Performance Framework' (Attachment A). The Global Fund recommends that the work plan and budget follow this same order. Where there are planned activities that benefit the health system that can easily be included in the tuberculosis program description (because they predominantly contribute to tuberculosis outcomes), include them in this section only of the Round 8 proposal. The overall goal of the Project is to drastically reduce the TB burden in Sudan, particularly among poor and vulnerable populations in line with the 2015 MDG and the Stop TB Partnership targets. While NTP and partners, with help of GFATM R5, has scaled up TB care based on DOTS, TB is still a public health emergency in Sudan. The estimated prevalence of TB is very high at 419 per 100,000 population. The high prevalence of TB is due to many factors, but there are three main gaps that should be urgently addressed. One is TB care in ongoing conflict and war areas, particularly in Darfur. Second is quality of DOTS. Third is incomplete TB care for other important areas like MDR-care, PPM and ACSM. The Proposal will therefore have five objectives to achieve: (1) Expand DOTS in war-affected areas particularly in Darfur and other States; (2) Pursue high-quality DOTS; (3) Address MDR-TB care & contact management; (4) engage all health care providers, and (5) Advocacy, Communication & Social mobilization. The first and second objectives are to respond to the first and second gaps mentioned above, and the third to fifth objectives are to respond to the third gap mentioned the above. At the same time, the R8 proposal will maintain the critical activities supported by R5 grant support once the R5 grant will end on 2010. The activities include: HRD including support for supervision, performance-based incentives and technical assistance, and provision of first line TB drugs. R8 will support such activities from 2011 which is Year 3 of R8 Proposal. Objective 1 Expand DOTS services, especially in war-affected areas in the

Western region (Darfur) and other states Access to TB care is limited in the conflict and war affected areas in Sudan, particularly in Darfur in Western Region. There are probably around 3 million displaced and refugee populations in Sudan (below). The Proposal aims at improving access to TB care in these areas through following activities. Targeted population: Total IDPs in the war-affected areas: 2.8 million9

(Darfur States: 2.5 million, Blue Nile State: 35 thousand South Kordofan State: 190 thousand, Eastern states: 170 thousand)

Refugees in Eastern States: Total 140 thousand refugees. Approximately 70-80% of all refugees and IDPs are women and Children.

SDA 1.1 DOTS EXPANSION IN WAR-AFFECTED AREAS NGOs currently providing TB patients services in the war-affected and the post-conflict areas will be identified. A needs assessment and situational analysis will be conducted through workshops where NGOs and state MOH officials will be invited. Available resources and

9 FMOH (2008)



facilities where Internally Displaced Population (IDP) camps will be identified. SNTP will partner with NGOs to deliver services in these areas. A MOU will be signed at the end of the initial discussions and workshops to outline roles and responsibilities of all partnered concerned. 1.1.1 Develop guidelines for DOTS in emergency situations by adopting the global guidelines according to the local situation

• A consultant will be contracted for 2 months to develop and finalize the guidelines, (including missions for the war-affected and post- conflict areas). [SNTP/WHO]

• A 1 day meeting will be organized to endorse the national guidelines (attended by SNTP staff, FMOH officials and WHO consultants). [SNTP/WHO] 1.1.2 Identify/develop partnership with NGOs in war-affected Darfur States

• Organise workshop for NGOS working in Darfur states, other post-conflict states and SMOH officials using the DOTS guidelines developed. Share information and identify partners willing concerned to with TB control.

• Two workshops, each 5 days long, will be conducted in Y1 with 30 participants per workshop.

1.1.3 Identify/develop partnership with NGOs in 5 post-conflict states

• One workshop will be conducted in each of 5 states (Blue Nile, South Kordofan, Kassala, Gedarif and Red Sea states) with 20 participants per workshop. • MOUs for delivering TB services between SNTP and NGOs will be signed at the end

of the workshops. [SNTP/WHO] 1.1.4 Provide equipment/supplies to TBMUs in Darfur and post conflict areas

• Thirty TBMUs and 90 DOTS centers will be established in Darfur states and post conflict areas.

Thirty TBMUs will be renovated and supplied with equipment. [SNTP/WHO] 1.1.5 Train health staff in Darfur states

• A 5 day training session will be conducted for 120 TBMU staff from 4 TBMUs per year for Y1-Y5.

• A 3 day training session will for conducted for 90 DOTS centre staff, per year for Y1-Y5. [SNTP/WHO]

1.1.6 Supervise TBMUs in war affected areas

• A 2 day meeting will be conducted with 15 Darfur task force members in Y1 with evaluation of the progress achieved conducted every 6 months thereafter for Y2-Y5.

[SNTP/WHO] • Supervisory visits will be conducted by 5 Darfur task-force supervisors on a quarterly

basis to TBMUs in Darfur states. [SNTP/Darfur task-force]

1.1.7 Provide incentives for newly established 30 TBMUs in Darfur states • Incentives will be provided for newly established TBMUs in Darfur states.

Objective 2: PURUSE HIGH QUALITY DOTS SERVICES The Proposal aims at scaling up and improving DOTS activities as core of TB care in Sudan. At present, DOTS is expanded with around 300 TBMU in Sudan. However, the quality of their DOTS services is not at the optimal level, in particular laboratory and M/E. The proposal will assist Sudan in improving the quality of DOTS care with the following SDAs SDA 2.1 IMPROVE DIAGNOSIS: CASE DETECTION THROUGH QUALITY- ASSURED BACTERIOLOGY



The laboratory network will be enhanced and quality assurance system improved. Peripheral microscopy laboratories will be renovated and culture will be introduced in 5 zonal laboratories. The national reference laboratory will be equipped to conduct DST effectively. This will assist in conducting the DRS survey under activity 2.1.2. External quality assurance will be implemented to support zonal and national reference laboratories 2.1.1 Improve and upgrade the microscopy laboratories network

• To improve the laboratory network, 105 TBMU laboratories will be renovated in Y1-Y5 in 15 states. • 105) laboratories will be rehabilitated and equipped with regular supplies instituted after

completion of R5 funding. [SNTP/NRL]

2.1.2 Provide National Reference Laboratory (NRL) with culture & DST equipment (liquid medium)

• To strengthen the capacity and improve performance quality of NRL, a MGIT/BACTEC machine will be procured with supplies and reagents in Y1Q1. Spare parts for the machine will be procured in Y3-Y5. [PR/NRP/NRL].

2.1.3 Develop guidelines for culture and Drug & Susceptibility Testing (DST)

• An international consultant will be contracted for 60 days to develop national guidelines for culture and DST.

• A 1 day meeting will be conducted to endorse the guidelines. Five hundred copies of the guidelines will be printed and distributed. [SNTP/WHO]

2.1.4 Provide external training on culture & DST and laboratory management

• A 2 week external training session will be conducted for culture DST and BACTEC technical issues, from Y1-Y5, each with 10 staff per year, from zonal and central TB laboratories.

• A one week annual refresher training will be conducted with central TB laboratory and external personnel and thereafter from Y2-Y5. [SNTP/WHO]

2.1.5 Provide 5 zonal labs with equipment and supplies for TB culture services

• Culture is now provided only at central laboratory and is not available at state or other levels.

• Equipment and supplies for culture will be procured for 5 zonal laboratories - 3 Labs in Y1 and 2 Labs in Y2. Spare parts will be procured in Y3 and Y5. [PR/SNTP]

2.1.6 Organise reliable logistics for specimens for DST

• A regular and reliable transportation system, with safety precautions, will be established for samples from zonal and state laboratories, to the national reference laboratory and [SNTP/WHO]

2.1.7 Provide performance-based incentive support for TB reference lab staff and 5 zonal labs

• Performance-based incentives will be paid to 24 NRL technical and support staff and 30 staff from 5 zonal laboratories staff, every quarter from Y1-Y5. [SNTP/PR/WHO]

2.1.8 Establish quality assurance program for proficiency testing for NRL

• As part of an external quality assurance system, the project will assist in proficiency testing. A laboratory in Belgium which has joint activities with NRL will carry out this activity. [SNRL/SNTP/NRL/WHO]

2.1.9 Provide technical assistance for 5 zonal culture laboratories

• One international expert will be recruited for 21 days every year from Y1-Y5 to provide



TA to 5 zonal labs. [WHO] 2.1.10 Procure First line anti TB drugs

First line anti TB drugs will be procured from Y3-Y5 (after completion of R5) SDA 2.2 MONITORING AND EVALUATION SYSTEM This SDA aims to enhance program management and M&E. Supervision guidelines and protocols for coordinators will be developed, and training, regular supervision and monitoring at all levels will be conducted. In R5, desktop computers were provided for each state office, but there is need to enable coordinators to send reports while on field M&E visits, and thus laptop computers with internet access will be provided for their move. Timely reporting, by state coordinators will be enhanced, Disease prevalence surveys will also be conducted in year 2 to measure the impact on TB care in TB epidemiology.. 2.2.1 Conduct supervision for 5 zonal culture laboratories

• To improve quality, quarterly supervision missions will be conducted to zonal laboratories by 2 central lab staff and one WHO staff members in Y1-Y5. [SNTP/WHO]

2.2.2 Provision of laptop and internet access to Scale up the computerized surveillance system

• In order to strengthen the electronic reporting system and facilitate data management and reporting in 15 states and the central unit, 16 laptop computers with internet network connectivity will be provided. [SNTP/WHO]

2.2.3 Develop a training manual on supervision for coordinators

• An international expert will be recruited for 30 days in Y1 to provide TA to 5 zonal labs. [WHO]

2.2.4 International and National technical assistance to provide SNTP program support through WHO personnel • Maintain technical support to SNTP by contracting one WHO international medical officer and two national staff for Y3 -Y5. [WHO]

2.2.5 Build staff capacity through participation in international workshops, trainings, meetings and conferences

• Ten personnel including; 4 laboratory, 4 clinical and 2 SNTP staff will attend International meetings, every year from Y1-Y5. [WHO]

2.2.6 Conduct TB disease prevalence survey

• A national TB disease prevalence survey will be conducted in Y2 to establish disease prevalence.

• An international consultant will be contracted for 30 days to lead the survey, support logistics, data entry, analysis, validation, report writing, printing and distribution of findings. • A one day field-worker training session will be conducted with 100 participants in Y2.

[SNTP/WHO] Objective 3 Prevent and control MDR-TB and address TB contact management SDA 3.1 ESTABLISH MDR MANAGEMENT IN SNTP The burden of MDR in the country is not known so SNTP proposes to conduct a nationwide survey. The survey aims to establish baseline data on MDR-TB. Guidelines for MDR TB



management will also be developed as will DR survey protocols and methodologies. Specialised training will be conducted for personnel working with MDR-TB. Materials and supplies for DRS will also be procured. The program will organize safe and effective transport for smears and cultures. 3.1.1 Develop MDR study protocol and methodology

• An international expert will be contracted for 30 days to develop the study methodology and support the study implementation, data analysis and report writing. The survey findings will be published and actively promoted. [WHO]

3.1.2 Conduct a Drug Resistance Survey (DRS)

• Materials and supplies for DRS will be procured. The program will arrange for the effective and safe transportation of smears and cultures and report on findings. [SNTP/WHO]

3.1.3 Develop guidelines for MDR patient management

• Technical assistance will also be secured for 30 days for the development and circulation of national guidelines for MDR management. [SNTP/WHO/TA].

3.1.4 Organize MDR TB training

• Two 5 day training sessions on MDR management will be organized for 30 staff in YR 1. A 2 day refresher training will be conducted every year after, from Y2-Y5. [SNTP/WHO]

3.1.5 Integrate management for MDR-TB patients in 1 regional hospital

• To accommodate MDR management integration into 1 regional hospital, a hospital will be renovated and provided with appropriate equipment and other supplies.[SNTP]

3.1.6 Procure 2nd line anti TB drugs for MDR TB

• In order to treat side effects of MDR-TB patients, second line anti TB drugs will be procured through the Green Light Committee (GLC). [SNTP/WHO].

3.1.7 GLC support. (USD 50,000 a year) SDA 3.2 ENSURE PROPER MANAGEMENT FOR HOUSEHOLD TB CONTACTS TRACING Research data indicates that incidence among TB contacts is higher than TB incidence in the general community. Therefore contacts of TB patients are considered a high-risk group for TB. The SNTP intends to develop targeted interventions to this high risk group to increases case detection and provide the necessary care and support. Guidelines for case contact tracing and management will be developed and piloted in 5 states. Subject to successful evaluation the program will be expanded to other states. Contact tracing, 3.2.1 Develop TB contacts management guidelines.

• An international expert will be contracted for 14 days in Y1 to develop the contact management guidelines. A 1 day seminar will be conducted to endorse the guidelines. Five hundred copies of the guidelines will be printed and distributed.

3.2.2 Train health care providers at pilot sites on TB contacts management.

• Two 4 day training sessions will be conducted targeting 30 health care providers each, from 5 pilot states. The 150 TB contact managers will be trained on contact tracing and management in Y1. A 2 day refresher training will be conducted annually from Y2-Y5. [SNTP/WHO]

3.2.3 Evaluate the pilot TB contacts management system implementation



• At the end of Y1, evaluation of the 5 pilot states will be conducted. An international expert will be contracted for 21 days to conduct the evaluation. The final report will be shared with partners.[SNTP/WHO]

3.2.4 Expand TB contacts management to other states

• Subject to successful outcomes of the contact management system, the program will be expanded to all states in a phased approach from Y2-Y5. Expansion during this period will include TOT - 30 trainers trained who will train another 900 health care providers in 300 TBMUs. [SNTP/WHO]

Objective 4 Engage all health care providers: Expand Public-Public and introduce Public-Private Mix approaches Engaging a number of different types of health care providers, both in public (non-NTP) and private, is extremely important for scaling up TB care in Sudan. The private sector, for example, is rapidly expanding in Sudan virtually without any control. Building of long term sustainable partnerships with public and private health service providers can therefore extend the reach of the SNTP and improve program quality. SNTP has spent considerable time examining a variety of PPM approaches utilising financial and incentives in order to achieve mid term targets and address low performing areas. It is proposed to expand on R5 PPM activities by trialing an incentives program to engage private and public partners in a number of states for the 5 year term of the grant. However, the current support and activities including ones from GF R5 are not sufficient to meet the extensive need. It does not allow NTP to involve more and more private and non-NTP public sector. The Proposal therefore includes the activities for rapidly scaling up PPM activities as well as pilot and scale up innovative approach in PPM. A rationale and methodology of the approach is provided in (Annex 6). SDA 4.1 Engagement of other health care providers in DOTS 4.1.1 Develop National guidelines for PPM.

• An international expert with adequate experience in PPM will be contracted for 14 days to provide technical assistance to develop national guidelines for PPM. [SNTP]

4.1.2 Conduct national and state PPM advocacy

• A 1day advocacy meeting will be conducted at national level to orientate 30 participants.

• A 1 day advocacy meeting in will be conducted with 20 participants each at state level in 7 states in Y1 and in the other 8 states in Y2-Y5 to orientate a total of 330 PPM administrators on PPM issues and approaches.

4.1.3 Conduct external training for PPM central unit, state staff and private health care providers

• Two PPM administrators will be externally trained each year from Y1-Y5 at a 6 day workshop: Total 10 PPM administrators trained.

4.1.4 Expand TB services in public health facilities – DOTS link

• 5 day training sessions, comprised of 20 participants each will be conducted in 5 states in Y1- total 500 people trained. The workshops will target health cadres in public health centers currently not providing DOTS services.

• The trained personnel will act as a link between the SNTP centres and non SNTP public centres.

• They will register all TB suspects or diagnosed patients and submit a report each



quarter to SNTP where results will be evaluated. • Reporting forms and other monitoring mechanisms will be agreed upon with DOTS

providers at identified service delivery points. • Following commissioning, incentives will be provided in Q4 of Y1. Incentives will be

provided on a quarterly basis, upon submission of audited reports. • Quality of the program administration will be assured through quarterly internal audits

from SNTP PPM managers. Payments will be according to performance. [SNTP/CU /State teams]

4.1.5 Provide incentives to private sector health care providers

• Following quality assurance, training and other incentives, an additional financial incentive of US$1 will be provided to health care providers for each sputum specimen forwarded for TB microscopy examination – a pilot project will be implemented targeting 50 private clinics for the first tow years, evaluation will follow to asses the pilot and expansion will follow in phase two (year 3-5) (US$15 thousand in Y1 & 2, US$16 thousand in Y3, US$17 thousand in Y4, and US$18 thousand in Y5).

4.1.6 Provide Incentives to private sector laboratory technicians

• Following quality assurance, training and other incentives, an additional financial incentive of US$1 will be provided to lab technicians for each positive sputum examination performed. a pilot project will be implemented targeting 50 private clinics for the first tow years, evaluation will follow to asses the pilot and expansion will follow in phase two (year 3-5) (US$ 15,000 in Y1 and Y2, US$ 16,000 in Y3, US $17,000 in Y4, and US$ 18,000 in Y5)

4.1.7 Provide Incentives to private patients who successfully complete treatment

• For patients attending private clinics, incentives will be paid to encourage treatment completion and reduce the default rate. An incentive of US$20 will be offered to the cured patient, subject to a final follow-up sputum examination by SNTP. a pilot project will be implemented targeting 50 private clinics for the first tow years, evaluation will follow to asses the pilot and expansion will follow in phase two (year 3-5) (US$10,000 for expected 500 cured patients in Y1&2 and 40,000 USD from Y3-Y5)

Objective 5 Raise TB awareness, build knowledge and create positive

perceptions toward TB prevention, treatment efficacy and adherence, and reduce stigmatizing attitudes.

ACSM has had support through R5 funding which specifically focussed on advocacy to increase political commitment and establishing DOTS committees in 8 States. As a result, ACSM staff has been contracted at national level and DOTS committees established. Some IEC materials have also been produced and distributed through TBMUs and schools. Small-scale media campaigns and community activities have also been conducted through DOTS committees and at National level, mainly in R5 years 1 and 2. An initial KAP survey is also being completed to gauge program impact to date. However, there is currently neither an ACSM strategy nor an operational plan and community awareness and social mobilisation for TB as a result of the current ad hoc approaches is still minimal. A more comprehensive, multi-level, integrated ACSM program now needs to evolve with a clear strategy. More stakeholders operating within existing networks have to be engaged to expand on the community reach of the program. Additionally, targeted interventions need to be developed to empower marginalized groups in war affected and post conflict areas. If successful, the more strategic, expanded program will be able to achieve measurable behavioural change to improve case detection and reduce the current high default rate. A rationale and methodology of the strategic ACSM approach is provided in (Annex 7)



SDA 5.1 ADVOCACY, COMMUNICATION AND SOCIAL MOBILIZATION (ACSM) 5.1.1 Build technical competencies for ACSM programming, monitoring and evaluation

• Establish a technical sub-Committee by Q2 of Y1 to support TB Board with specialists for ACSM programming – community based and mass media programming and dissemination, and Monitoring and Evaluation – formative research, communication pre-testing and impact evaluation.

• Conduct quarterly meetings from Q2 of Y1 to Q4 of Y5 to plan, develop, implement and evaluate the ACSM strategy (see ACSM strategic approach – Appendix 2). [Activity cost – Technical sub-Committee meetings and venue hire = US$13,320 SNTP/WHO]

5.1.2 Operationalise the ACSM program

As well as developing a cohesive ACSM strategy, ownership and participation will have to be instilled with key program stakeholders. • An international technical advisor will be contracted for 30 days in Y1-Y2 to assist in developing the ACSM strategy and operationalising it through integrated national and state workplans. • An international ACSM technical advisor will also be contracted for 30 days in Y1-Y5

to assist in developing a training manual on advocacy and IEC core materials.[Activity cost – sixty days of TA across 5 years = US$30 thousand - SNTP/WHO/NGOs]

5.1.3 Generate earned media through media conferences and events Generating earned media opportunities through ACSM program launch activities is

important to raise the profile of the TB program with opinion leaders and the general public. • Four annual media events will be conducted at national each year from Y2-Y5. [Activity cost – Media event materials = US$7,300 - SNTP/WHO] • A public relations consultant will be contracted from Y2-Y5 to support staging of the

events and ensuring that the media attend.[Activity cost – US$60 thousand - Private Partner]

5.1.4 Expand existing ACSM networks by engaging health educators, NGOs and civil

society There is currently a large untapped network of health workers across Sudan working within government, national and international NGOs, and civil society. It will be important to engage these sectors in the expanded program to ensure synergies are achieved. • Training, IEC materials and other incentives will be provided to these groups from Y2-

Y5. [Activity cost – Training and IEC materials support = US$90 thousand - TPA /SNTP].

5.1.5 Build capacity for TB advocacy with the media

Journalists can be strong advocates for generating earned media opportunities for TB control in print radio and television media. The hot-news generated is more powerful than paid media approaches and relatively inexpensive to generate. • Quarterly breakfast meetings and annual workshops will be conducted for the

journalists association from Y2-Y5. [Activity cost – media workshops = US$27,700 - TPA /SNTP].

5.1.6 Build capacity with TB staff on health communication skills. Improved case finding and treatment outcomes are the key to TB control. Low case detection is likely due to poor communication by health staff. This activity aims to improve case detection by providing TOTs to identified health workers, to improve communication skills with patients. This will be combined with the practical application using Best Practice for the care of patients with tuberculosis: A guide for low-income countries” (The Union, 2007).



• A 6 day training session will be conducted for 20 trainers including TB program staff, TB patient association staff and other health care providers each year in Y1-Y2-Y3. [SNTP/Epi-lab]

5.1.7 Engage vulnerable groups through mobile cinema in post conflict areas

Enter-education has been identified as a potentially powerful medium with population groups who have little opportunity for celebration and socialization. This is the case with IDPs in post conflict areas. • Four audio-visual tool-kits will be purchased in Y1, each comprised of a powerful LCD

projector, public address system, screen and generator [Activity cost – AV-toolkits and carry cases - $80 thousand]

• A trigger discussion film will be produced in Y1 to explore a range of TB related scenarios including, stigma, treatment delay, gender issues, public private options, treatment efficacy and adherence [Activity cost – $30 thousand]

• A regional presentation team comprised of a group moderator, successfully treated patient and clinician will conduct trigger film presentations, discussions and screening for TB in 50 annual 2 day sessions in IDP camps and post conflict areas in Y2-Y5. [Activity cost – US$120 thousand: Total activity cost = US$230 thousand - TPA/ WHO/SNTP/].

5.1.8 Produce and ensure continuous supply of quality IEC materials

A core set of quality assured IEC materials will be produced and a Communication Resource Information System (CRIS) established to ensure continuous supply of IEC materials when and where they are needed. • A private sector agency will be contracted by Q2 of Y1 to produce IEC materials – Flip

charts, DOTS provider cards, advocates info sheets, and TB merchandise – bags, scarves, caps, t-shirts and banners.

• A communication resource logistics system and database will be established in Y1 to manage distribution and reprinting of IEC materials.

• IEC materials will be distributed at all training sessions from Y2-Y5 to all state SNTP/MOH, NGO and civil society offices to support intensive 6 week programming periods. [Activity cost – Two million IEC materials produced and distributed = US$149,500 - WHO/SNTP].

5.1.9 Produce and disseminate quality electronic, print and outdoor media materials

Mass media is an important component of ACSM to ensure a high profile for the program with opinion leaders. It can also create an intensive ‘media umbrella’ to support community based programming and social mobilisation. • Private sector communication partners will be contracted and briefing documents

provided in Y1 for development and pre-testing of communication materials – creative concepts and national brand.

• Media materials will be developed and disseminated through relevant media during intensive 6 week annual programming period from Y2-Y5 commencing on World TB day. [Activity cost – Four media campaigns, at least 30 spots per week on 8 main stations – 1440 radio/TV spots per each intervention period = US$780 thousand -WHO/SNTP]

5.1.10 Conduct Annual KAP Surveys Operational Research A post intervention survey (operational research) will be conducted annually to measure ACSM program impact.

• An international consultant will be contracted for 30 days in Y1-Y2 to develop the survey methodology – sampling frame, questionnaires, training of field workers, data entry, analysis and report writing.

• An annual KAP survey will be conducted from Y2-Y5 after each intensive 6 week programming period. [Activity cost – Four KAP surveys - US$30 thousand each =



US$120 thousand - WHO/SNTP/Epi lab] 5.1.11 Conduct message pre-testing for ACSM communication program.

Concepts and messages developed by the communications agency will require pre-testing to provide evidence based, high impact ACSM programming. • An indep • endent market research partner will be contracted in Y1. Pre-testing for the Phase 1

intensive programming period will be conducted in the last quarter of Y1. • A pre-test will be conducted for each subsequent Phase of intensive programming

period in the last quarter of Y2-Y4. [Activity cost – Four pre-tests at US$15 thousand each = US$45 thousand - WHO/SNTP/Epi Lab]

SDA 5.2 COMMUNITY TB CARE 5.2.1 Expand community volunteer networks and develop guidelines

DOTS committees at village levels will be formed to work as community volunteers. Volunteers will be trained to support DOTS providers for community surveillance, referrals, community DOTS administration and TB prevention advocacy. • A consultant will be contracted for 14 days to produce community volunteer guidelines

for TB control. • Thirty 3 day workshops will be conducted in Y1-Y5 to train 180 community volunteers

annually. IEC and other support materials will be disseminated. • Quarterly supportive supervision and M&E will be provided for volunteers by state

coordinators. [Activity cost – 900 volunteers trained = US$53,500 thousand - SNTP] 5.2.2 Empower TB patients and their families through supportive environments

TB is largely a disease of poverty. This activity aims to support livelihoods of TB patients who

have lost their earning capacity.

• Three hundred TB patients in five States will be provided with income generating opportunities including mixed farming, food processing, knitting and tailoring schemes in Y1‐Y5.

• A social worker will be recruited to supervise and coordinate the activities from Y1‐Y5. [Activity cost – 300 beneficiaries x US$200 = US$60 thousand + US$40 thousand for supervision and evaluation ‐TPA NGO]

5.2.3 Support TB female patient empowerment

TB treatment delay with women is high as a result of high rates of stigma. Women’s empowerment is a key to more successful prevention and treatment outcomes. Ten bi-annual 1-day seminars will be conducted for women leaders in Khartoum state to advocate for TB control. [Activity cost – 175 beneficiaries trained = USD$24,800 - IWC NGO]

4.5.2. Re-submission of Round 7 (or Round 6) proposal not recommended by the TRP

If relevant, describe adjustments made to the implementation plans and activities to take into account each of the 'weaknesses' identified in the 'TRP Review Form' in Round 7 (or, Round 6, if that was the last application applied for and not recommended for funding).

N/A The TRP review form in R7 described the following weaknesses which were subjected to proper adjustments in this proposal:

The proposal is not technically sound and is missing a description of proposed interventions. There is no clear description of how the basic TB Control program is functioning and how it will be strengthened using the basic DOTS components.



Adjustments: The proposal development process has been upgraded through the involvement of national and international consultants with experience in TB control. In addition, the draft strategy has been circulated to all partners in order to obtain their inputs and comments to improve the quality of the final submission. The final selected interventions are evidence-based and every effort has been made to ensure clear and coherent. Innovative approaches. Suggestions to improve the performance and efficiency of the NTP through DOTS expansion in the war-affected and post-conflict states has been addressed through the establishment of partnerships with NGOs working in these areas. Other initiatives include, piloting of TB contact management, addressing quality issues within the DOT service areas, scaling up of the surveillance system through the establishment of an electronic reporting system at the state level and capacity building of staff in effective communication and advocacy. There are extremely low case detection rates in different parts of the country, from 2% to 23% (4.3.2.

b); however, the proposal does not explain how this issue will be addressed and what will be the contribution of smear microscopy to reaching the case detection rate target

Adjustments: The low case detection rates across the country have been addressed through DOTS expansion to the war-affected and the post-conflict areas (CDR about 16%) in order to increase the CDR in these areas and consequently the whole country CDR. Considering the other states, the quality of the provided DOT services is planned to be improved to increase CDR and to reduce the defaulting rate. The renovation of 105 peripheral laboratories with establishment of quality assurance system is expected to positively contribute to increase detection rates. The contacts of TB patients are considered a high-risk group for TB. The SNTP intends to develop targeted interventions to this high risk group to increases case detection and provide the necessary care and support. In addition expansion of DOT to other public health facilities and private clinics can contribute to increased case detection. It is unclear how the following different intervention components will be implemented: MDR TB,

establishment of a House Hold Contacts Management system. Adjustments: The burden of MDR in the country is not known so SNTP proposes to conduct a nationwide survey. The survey aims to establish baseline data on MDR-TB. Guidelines for MDR TB management will also be developed as will DR survey protocols and methodologies. Materials and supplies for DRS will also be procured. The establishment of the of house hold contact management system has been clarified in order to support the implementation process including: piloting in 5 states, development of guidelines, evaluation of the piloted system in the five states, technical support with international and international experts and training of trainers to facilitate the implementation of gradual expansion to other states with close and efficient monitoring and supervision. • The impact indicators are extremely ambitious for the country context and appear to be difficult to reach

in the context of the description of planned activities included in the proposal: For example: increase case detection rate from 35% (2005) to 54% (year1), reduce the TB incidence from 228/100,000 (2005) to 200/100,000 (year 1), percentage of household contacts examined out of eligible increasing from 40% at month 18 to 100% at month 24.

Adjustments: The impact indicators have been revised in order to render them reasonable, achievable and feasible within the life span of the project. • The financial gap analysis only mentions some donors, and there is no mention of the Islamic

Development Bank grant. Adjustments:

The Islamic Development Bank grant had focused on improving the external quality assurance of smear microscopy throughout the laboratory network. It managed to construct 15 state quality assurance laboratories. The project has been finalized since 2006.

• There is no clear description of what the income generating activities are devoted to: animal husbandry scheme for cow, goats and sheep and how these will be implemented.



Adjustments: The income generating schemes aim to empower economically the TB patients and their families. This will include implementation of different types of income generation schemes according to the area of implementation, and recruitment of a social worker with adequate experience on IGAs to supervise the implementation process. The activity targets both male and female patients. In the rural areas most of the families are headed by females and so when they become tuberculosis, the whole family breadwinning is seriously affected. It is expected that the IGAs will improve the overall family economical status. In situations where male patients are affected, the activity is expected to target both male and female patients in the same family. This will markedly improve the overall family well-being and welfare. There is no explanation of how security issues related to the project will be addressed for conflict

areas, such as Darfur. Adjustments: Security risks and other challenging issues will be minimized through partnerships with NGOs, civil society organizations and collaboration with UN agencies and offices in the war-affected and post-conflict areas.

4.5.3. Lessons learned from implementation experience

How do the implementation plans and activities described in 4.5.1 above draw on lessons learned from program implementation (whether Global Fund grants or otherwise)?

The DOTS is widely implemented across the country but the quality issues are poorly addressed in the delivered services. The case detection rate is low in the war-affected areas and this has affected adversely the national detection rate. Thus it is necessary to address the quality issues in the different states but still the expansion of the DOTS services is the major concern in the war-affected areas.

Despite the SNTP efforts in strengthening the managerial capacities at different levels but still the management capacities at the state and locality level are inadequate. The same is applicable for the supervisory system which is adequately functioning at the national level but not existing in lower levels.

Political commitment and support for the TB control is still inadequate at both the federal and state levels. Effective advocacy efforts are to be intensified targeting the parliamentarians, policy-makers and decision-makers to accomplish policy changes and resource mobilization.

Data from countries highlighted that incidence among TB contacts is higher than the incidence of TB in community, and therefore contacts are considered as high risk group and a source for cases. This part of TB control remains neglected during the previous period of TB control in Sudan. However the new stop TB strategy pointed out to this challenge under the second component of the strategy. The SNTP will address this strategy as one of the tools to increase the low case detection rate across the country.

The magnitude of the MDR in Sudan is not yet documented and quantified. There is a real need to start during this phase to avail information about MDR in order to develop and implement evidence-based strategic approaches.

The non-SNTP providers may serve a large proportion of TB patients and suspects but may not always apply recommended TB management practices or report their cases to SNTPs.

Pulmonary TB is often manifested as a cough, and people with TB symptoms first present to primary care services as respiratory patients. By linking TB control activities to proper management of all common respiratory conditions, SNTPs and the staff who implement DOTS services at local level can help to improve the quality of care and the efficiency with which it is provided. The poor socio-economic status of many TB patients is aggravated when they become ill as a number of the TB patients are dismissed from their jobs. The whole family status is affected especially if the main breadwinner is the mother as is the situation in many rural areas. Thus it is necessary to develop innovative approaches to empower TB patients and their families.



4.5.4. Enhancing social and gender equality

Explain how the overall strategy of this proposal will contribute to achieving equality in your country in respect of the provision of access to high quality, affordable and locally available tuberculosis diagnosis treatment and care and support services.

(If certain population groups face barriers to access, such as women and girls, adolescents, sexual minorities and other key affected populations, ensure that your explanation disaggregates the response between these key population groups).

The overall strategy of this proposal will contribute to social equality across the country as one the objectives is to expand the DOTs to the war-affected areas in order to provide quality accessible services for the displaced camps in Darfur States. In addition the DOTS will be expanded to the rural populations in the war-affected areas who are currently under-served.

The proposed income-generating schemes (IGAS) target both male and female patients. In the rural areas most of the families are headed by females and so when they become tuberculous, it is expected that the IGAS will improve the overall family status. In situations where male patients are affected, the activity is expected to target both male and female patients in the same family. This will markedly improve the overall family well-being and welfare.

All the objectives in this proposal have a focus on equity issues. One of the main principles of equity is that all MDR TB suspects, irrespective of their gender, race, religion, or geographical location are entitled to free access to TB diagnosis through sputum microscopy. Besides, all TB patients, irrespective of the type of disease and HIV-status, are entitled to free treatment from the SNTP. On the other hand, activities of DOTS strengthening will try to bridge the gap between different regions in the country and to achieve a balanced distribution of services between urban and rural areas.

In this proposal we are trying to focus on gender inequities regarding accessibility and program management at the level of:

Health staff: one of the main visions of the SNTP is to secure gender-balance in capacity building. This has been taken as an indicator of performance with regard to training. In this proposal the same approach will be ensured so that capacity building is gender-oriented.

Community: through various interventions targeting communities, gender-linked accessibility barriers will be one of the main tasks of implementers. In addition, balanced gender involvement in various activities such as DOTS supervisors, TB patients’ association, and TB volunteers will be carefully considered. Some of the interventions like TB in primary schools are expected to mainly target females.

Urban Vs Rural inequity: the first objective will be to ensure univesal access to TB culture in the rural areas through the 5 decenteralized zonal labs.

4.5.5 Strategy to mitigate initial unintended consequences

If this proposal (in s.4.5.1.) includes activities that provide a disease-specific response to health system weaknesses that have an impact on outcomes for the disease, explain:

the factors considered when deciding to proceed with the request on a disease specific basis; and

the country's proposed strategy for mitigating any potentially disruptive consequences from a disease-specific approach.

NA



4.6. Links to other interventions and programs

4.6.1. Other Global Fund grant(s)

Describe any link between the focus of this proposal and the activities under any existing Global Fund grant. (e.g., this proposal requests support for a scale up of ARV treatment and an existing grant provides support for service delivery initiatives to ensure that the treatment can be delivered).

Proposals should clearly explain if this proposal requests support for the same interventions that are already planned under an existing grant or approved Round 7 proposal, and how there is no duplication. Also, it is important to comment on the reason for implementation delays in existing Global Fund grants, and what is being done to resolve these issues so that they do not also affect implementation of this proposal.

The CCM Northern Sudan have approved funding from GFATM Round 5.

Through the R8 proposal the CCM Northern Sector will ensure that there is no duplication and this proposal complements the areas proposed for R5 activities. The interventions selected for R8 have taken into consideration the absorbtive capacity of the Principle recipient and all Sub-ricipients,guided by the factors that caused performance delays of R5.

How to insure that there is no Duplication :-

The table below indicates the areas covered by R8 and R5 ,with an explantion on how duplication has been avoided:-

Round 5 interventions Round 8 interventions How to ensure that there is no

Duplication

Human resources (building capacity) Build cabacity of TB staff on

health communuication skills,contact mangement ,culture and DST

All the training activities under round 5 are basic training for health cadrs working in the TBMUs ,while through round 8 proposal all the training will be for a newly introduced intervensions.

Human Resources (maintaining staff) Provide incentives for newly

established zonal labs and 30 TBMUs in Darfur State

While round 5 provides incentives for the already working TBMUs ,round 8 will provide incentives for the new staff ,other than those covered by round 5

Health infrastructure development (strengthening supervision).

NON The round 8 project will make use of the infrastrcures provided under round 5 ,as it will use the same cars to supervise the new intervensions besides the old ones.

Human resources (strengthening supervision). Conduct supervision for 5

zonal culture labrotaries. Although the NRL will use the infrastrucure of round 5 ,it’s apparent that supervising culture labs need special experties different from those supervising the Basic MUs.

Procurement and supply management system (procurement of anti-TB drugs and lab supplies).

Procure second line anti TB drugs ,and lab equipment and supplies for culture labs.

Under round 8 ,the second line drugs will be procured which have not been under round 5,besides the equipment and reagent for the culture labs which is introduced as a new intervention.

Monitoring and Evaluation (strengthening health

Conduct KAP surveyus following annual intensive

Only one previous survey has been conducted which focussed primarily on prevalence. R* will



information system). programming for ACSM to measure behavioural impact

be operational surveys (smaller smaple sizes) and directly linked to measure the impact of ACSM interventions.

Operational Research. Greater focus on operational research through annual surveys with standardised indicators. Baseline established in 2nd year of R8.

None previously conducted. Limited community based operational research will need to be institutionalised through standardised methodologies, indicators and sintruments.

Advocacy & increased political commitment to DOTS (sensitizing policy makers to TB).

More concentrated strategic approach with intensive phases of activity to set the TB program agenda.

Previous approach focussed on worshops with limited support to advocates and minimal impact through media approaches which is noticed by opinion leaders.

BCC-Community outreach: a. DOTS committees: b. TB patient association:

Expansion of DOTS committees proposed with greater support through BCC messaging, training and continuous IEC materials support.

Previous approach to resourcing was ad hoc and limited in reach of IEC materials. A more strategic approach to programming through DOTS committees, TB patient associations and other civicl society agencies is proposed for R8.

Behaviour Change Communication- Mass media R8 will embark on a more

strategic, multilevel, intensive, media programming to support community based IPC approaches. Mass media will set the program agenda through the development of a national brand to be applied to all materials.

R5 provided a platform for the development of some IEC materials and programs. This process will now have to be more evidence based through the contracting of private sector partners, message pre-testing and contimuous supply of IEC mass media materials and logistics to support community programs.

Coordination and partnership development (PPM). Engagement of other health

care providers in DOTS Through round 5 the Puplic Puplic partenership have been develop ,and by this round the public private partenership will be introduced

Prevention of HIV in TB patients. None

Intensified TB case finding in PLWHA. None

How does this proposal complement the R5 proposal? :-

Through the R5 grant, the CCM Northern Sector Sudan ,aimed to streghnth the basic TB control services along with the introduction of new interventions. This proposal aims to adopt new strategies (that have not been tackled by R5) as well as biuld on what has been achieved to date by round 5.

By introducing TB control activities in Darfur ,the proposal makes use of the basic services strengthening done in the Darfur region. However, this will allow for scaling up of the population numbers and geographical boundaries for available services to cover TB patients in wider number of IDP camps..Moreover,the partership with NGOs can benefit the program in the long term to cover other affected populations in other regions of the country. The guidelines developed under this project ,can be used to also guide TB activities in emergency stituations that may arise in the future.

Providing microscopes ,reagents and training of labrotory techenicians on smear microscopy were the focus of the Global Fund grant R5. Establishing the zonal labrotory ,along with cabacity building of the NRL on culutre and DST are complementing the establishment of a lab network that is able to diagnose correctlly all TB patient types ,including MDR TB patients.

As mentioned in the above table, R8 will introduce a more comprehensive Public Private Mix for DOTS which will make use of the experience gained in R5 in developing partenerships with public providers,and constitute the full adoption of the PPM startegy by including the biggest health care provider sectors in the country.



4.6.2. Links to non-Global Fund sourced support

Describe any link between this proposal and the activities that are supported through non-Global Fund sources (summarizing the main achievements planned from that funding over the same term as this proposal).

Proposals should clearly explain if this proposal requests support for interventions that are new and/or complement existing interventions already planned through other funding sources.

The interventions for R8 are not a duplication of any efforts of other donors. Moreover, this proposal is not seeking to complement any activities covered by other donors. LHL is planning to support ACSM in areas other than activities covered by GF, WHO (JPRM) IDB mainly supports lab (EQA) and related HRD. There are no challenges facing duplicate activity support from other partners.

4.6.3. Partnerships with the private sector

(a) The private sector may be co-investing in the activities in this proposal, or participating in a way that contributes to outcomes (even if not a specific activity), if so, summarize the main contributions anticipated over the proposal term, and how these contributions are important to the achievement of the planned outcomes and outputs.

(Refer to the Round 8 Guidelines for a definition of Private Sector and some examples of the types of financial and non-financial contributions from the Private Sector in the framework of a co-investment partnership.)

NA

(b) Identify in the table below the annual amount of the anticipated contribution from this private sector partnership. (For non-financial contributions, please attempt to provide a monetary value if possible, and at a minimum, a description of that contribution.)

Population relevant to Private Sector co-investment (All or part, and which part, of proposal's

targeted population group(s)?)

Contribution Value (in USD or EURO) Refer to the Round 8 Guidelines for examples

Organization Name

Contribution Description

(in words) Year 1 Year 2 Year 3 Year 4 Year 5 Total

[ use “Tab” key to add extra rows if needed]



4.7. Program Sustainability

4.7.1. Strengthening capacity and processes to achieve improved tuberculosis outcomes

The Global Fund recognizes that the relative capacity of government and non-government sector organizations (including community-based organizations), can be a significant constraint on the ability to reach and provide services to people (e.g., home-based care, outreach contact, orphan care, etc.).

Describe how this proposal contributes to overall strengthening and/or further development of public, private and community institutions and systems to ensure improved tuberculosis service delivery and outcomes. Refer to country evaluation reviews, if available.

The proposal aims to expand the DOT services to the internally displaced populations in the war-affected and post-conflict areas. Such approach is expected to avail the services for the underserved internally displaced peoples and to increase case detection and management.

The proposal is expected to contribute to strengthening of the NGOs in the war-affected and post-conflict areas through development and implementation of partnership protocols. The capacity building of the NGOs in management and service delivery is addressed within the designed activities. In addition the proposal aims to improve the quality of the DOT services in the war-affected and post-conflict areas and other states through operationalization of TB service standards and use of guidelines and training of the health care providers.

In addition the proposal aims to improve and strengthen the current laboratory and culture services, especially in the rural areas and this is expected to improve the quality and availability of TB services.

The proposal also addresses MDR TB as one of the priority areas through activities such as a national survey, case detection and management. These approaches will effectively contribute to improved TB service delivery.

The proposal also plans to pilot and expand the contact detection system in order to increase the case detection rate and to manage patient contacts in the family, at school and in work places.

The proposal also plans to strengthen DOTS committees at different levels with training of volunteers at the community level. This is expected to improve community-based TB care delivery and service coverage.

The planned income generating schemes aim to economically empower TB patients and their families in order to improve their socio-economic status. Such activities can positively influence the health status of the TB patients and their families.

The proposal also aims to contribute towards strengthening the health care system directly through implementation of PPM activities. Additionally, there are other planned activities i.e. policy formulation, advocacy seminars, IEC messages, training which will also have an impact on the health system.

4.7.2. Alignment with broader developmental frameworks

Describe how this proposal’s strategy integrates within broader developmental frameworks such as Poverty Reduction Strategies, the Highly-Indebted Poor Country (HIPC) initiative, the Millennium Development Goals, an existing national health sector development plan, and other important initiatives, such as the 'Global Plan to Stop Tuberculosis 2006-2015' for HIV/TB collaborative activities.

Interventions for tuberculosis control can be seen from a socio-economic perspective as measures targeting poverty reduction. This holds true, when most of TB patients are among economically active age groups, besides the devastating loss in income due to the debilitating nature of disease. Apart from the fact that TB sufferers might be forced to be away from work for long periods, most of those patients are forced to quit working as a result of the social stigma stamping disease and patients. The situation is even worse in some parts of the Sudan, where patients are really segregated in such way that no body is willing to deal with the whole family and even no one will approach that family for marriage. The impact of different interventions in this proposal for controlling TB especially the income



generating schemes is henceforth not separating from the context of poverty reduction strategies. TB control is tightly linked to MDGs at least in two aspects. Firstly, as being a measure for reducing poverty and secondly as falling within goal number 6. In Sudan, this linkage has been translated in the 25-year strategic plan for health as: Goal 6 of the MDGs targets for 2015 to halt and begin to reverse the spread of HIV/AIDS and the incidence of Malaria, Tuberculosis and other major diseases. On the other hand, TB/DOTS represents a doorway for the WHO/UNAIDS “3-by-5 initiative”. This holds true when consensus has been made to use TBMU as an entry point for ART. In past years, the SNTP has been strongly linked to and part of the Global plan to stop TB. There is close collaboration and meticulous follow-up from both WHO and the IUATLD on TB control activities in Sudan. This has materialized through regular monitoring and evaluation carried out annually during the agency technical advisory visits (TAC).

4.8. Measuring impact

4.8.1. Impact Measurement Systems Describe the strengths and weaknesses of in-country systems used to track or monitor achievements towards national tuberculosis outcomes and measuring impact. Where one exists, refer to a recent national or external evaluation of the IMS in your description.

The current SNTP surveillance system is organized according to the IUATLD guidelines. Patient information, diagnosis, treatment regimen and compliance are registered on patient’s treatment cards. Data regarding diagnosis, smear results, outcomes, place of treatment are registered on the tuberculosis management unit (TBMU) treatment register.

Laboratory results of sputum examination per patient are registered in the laboratory register. Quarterly reports are compiled by each TBMU and forwarded to the state coordinator. The data is then compiled and forwarded to the SNTP. The SNTP is responsible for summarizing all case finding, treatment outcome, and analyzing data. The system of reporting is paper-based and some of TB management units do not regularly report to the state coordinators especially in the war-affected and post-conflict areas.

The quarterly and the annual reports are usually available at the SNTP level. They are used regularly for monitoring and evaluation. The information is not included in the state and federal annual statistical reports. The system is not integrated within the national health information system at both the federal and state levels. This has two negative effects: the first is the incompleteness of the data base at both the state and federal levels and the second is limitation of dissemination and utilization of the surveillance information. The surveillance system is chronically suffering from staff turnover and instability. Other weaknesses include: lack of feed-back mechanisms and non-utilization of the surveillance information especially at the levels of collection.

The supervisory system: the system is composed of three levels: central, state and locality Currently, there are standard checklist and guidelines for supervision which are used for conduct of supervisory visits at different levels. The supervisory system is adequately functioning at the national level but does not exist at other levels.

The obstacles for the system include, lack of methods of transport, delay of fund release results in failure of conduct of supervisory visits, turnover of the staff, non-motivation of the staff. The supervision capacity of the staff especially at the state level is poor and this adversely affects the performance at lower levels. The overall system is poorly functioning and need to be scaled up and strengthened.



4.8.2. Avoiding parallel reporting

To what extent do the monitoring and evaluation ('M&E') arrangements in this proposal (at the PR, Sub-Recipient, and community implementation levels) use existing reporting frameworks and systems (including reporting channels and cycles, and/or indicator selection)?

The SNTP surveillance records and report format are to be used at different levels by all sub-recipients and facility staff. The NGOs in the war-affected areas are expected to use the SNTP format and as well submitting their reports to the TB State Unit where compilation and processing are to be conducted with other reports from TBMUs. In addition the training on surveillance and data management will be held jointly to ensure adequate consistency of the system.

In addition the list of indicators will be standardized in order to strengthen the monitoring and evaluation performance at different levels. In addition joint monitoring and evaluation with representation of all partners with regular dissemination and feed-back of the reported information will be addressed.

The standard checklist and the guidelines for supervision will be used for conduct of supervisory visit. The visits reports will be standardized and the flow channel of the reports will be agreed upon in order to avoid parallel reporting.

4.8.3. Strengthening monitoring and evaluation systems What improvements to the M&E systems in the country (including those of the Principal Recipients and Sub-Recipients) are included in this proposal to overcome gaps and/or strengthen reporting into the national impact measurement systems framework? The Global Fund recommends that 5% to 10% of a proposal's total budget is allocated to M&E activities, in order

to strengthen existing M&E systems.

The M&E can be improved through expansion of the electronic reporting system to all states. This is expected to upgrade the surveillance system and to avail the information needed for monitoring purposes and decision-making process at the central level. In addition the electronic reporting system is expected to facilitate access to information at the state level and thus use can be increased markedly. In addition the proposal is addressing the strengthening of the feed-back mechanisms within the system and this is expected to improve the quality of the information especially at the facility level.

Strengthening the supervision system at different level can effectively contribute to monitoring of the implemented activities and as well timely adjustment and modification can be performed. Capacity building and training of the staff on health management with focus on monitoring and evaluation can improve the efficiency of the system.

The conduct of the annual and mid-term review of the program by external evaluators can positively affect the overall implementation process. Integration with the National Health Information system at different levels can improve the performance of both systems and facilitate the monitoring and evaluation of the program performance.

4.9. Implementation capacity

4.9.1 Principal Recipient(s) Describe the respective technical, managerial and financial capacities of each Principal Recipient to manage and oversee implementation of the program (or their proportion, as relevant). In the description, discuss any anticipated barriers to strong performance, referring to any pre-existing assessments of the Principal Recipient(s) other than 'Global Fund Grant Performance Reports'. Plans to address capacity needs should be described in s.4.9.6 below, and included (as relevant) in the work plan and budget.

PR 1 United Nation Development Program Sudan (UNDP)

Address [street address] Tel: +249 (0) 15-577-00-70/71/72/73 ext.117 Fax: +249 (0) 183 783 764



Mob: +249 (0) 91 250 13 20 E-mail: [email protected] United Nations Development Program House # 10, Block 6 - Z Mc Nimir street, P.O. Box 913 Khartoum, 11111 Sudan

United Nation Development Program Sudan (UNDP) is engaged in 166 countries in the world in the management of the programs funded by the international communities. UNDP programs include Poverty reduction, Gender, Human Rights, environment, food security, community empowerment, capacity building of the public institutions and civil society. Comparative advantage of UNDP in provision of long-term development programs with active participation and ownership of the local community ensures sustainability, efficiency and effectiveness of UNDP initiatives. UNDP program in Sudan provides humanitarian, recovery and reintegration, management support to international assistance and support the office of the UN Resident and Humanitarian Coordinator for the Sudan.

PR 2 [Name]

Address [street address]

[Description]

PR 3 [Name]

Address [street address]

[Description]

Copy and paste tables above if more than three Principal Recipients

4.9.2 Sub-Recipients

x Yes

(a) Will sub-recipients be involved in program implementation?

No

(b) If no, why not?

x 1 – 6

7 – 20

21 – 50

(c) If yes, how many sub-recipients will be involved?

more than 50

x Yes [Insert Annex Number for list] (d) Are the sub-recipients already identified?

(If yes, attach a list of sub-recipients, including details of the 'sector' they represent, and the primary area(s) of their work over the proposal term.) No

Answer s.4.9.4. to explain

(e) If yes, comment on the relative proportion of work to be undertaken by the various sub-recipients. If the private sector and/or civil society are not involved, or substantially involved, in program



delivery at the sub-recipient level, please explain why.

World Health Organization (WHO) was identified as the main (only) sub-recipient; others will be sub-sub-recipient for the grant.

The NGOs will be fully committed in the delivery of the TB services for the internally displaced population in the war-affected areas. The training of the health care providers in the service delivery points in the war-affected areas will be undertaken jointly between the SNTP, the NGOs, the State Ministry of Health and the concerned academic institutes in the area. This can be effectively accomplished through establishment and implementation of partnership with the NGOs currently delivering services in the war-affected and the post-conflict areas. Such partnership may encourage other partners to address TB within their activities in the war-affected areas.

The capacity building of the human resources of the National reference laboratory will be partly covered by the Islamic Bank which a private enterprise. This is an example of local contribution of the private sector in human capacity and infrastructure building.

The income generating schemes will be fully undertaken by the TB Patient’s Association and the International Mother and Child Organization. The two NGOs will jointly committed in implementation of the income generating activities with the targeted TB patients especially in the rural areas.

The proposed ACSM activities are planned to be jointly implemented between the SNTP and the TB Journalists Association.

4.9.3. Pre-identified sub-recipients

Describe the past implementation experience of key sub-recipients. Also identify any challenges for sub-recipients that could affect performance, and what is planned to mitigate these challenges. The TB Patients’ Association and the international Mother and Child Organization have been committed in income generating activities in similar projects and they therefore have adequate experience in Implementing the proposed current activities. The TB Patients’ Association have also been implementing ACSM activities, especially in the rural areas. The International Mother and Child Organization has been Involved in social support of street children and orphans in Khartoum state. The TB Journalists Association has had previous experience in delivering advocacy/IEC messages to the public in collaboration with NTP and other partners.

4.9.4. Sub-recipients to be identified

Explain why some or all of the sub-recipients are not already identified. Also explain the transparent, time-bound process that the Principal Recipient(s) will use to select sub-recipients so as not to delay program performance.

Some sub-recipients in the war and post-conflict areas were not yet identified although they showed interest in TB control activities based on the initial contacts with the concerned officials. The planned selection process will be through establishment of partnerships and joined activities and meetings early in the first year of the program to ensure early commitment. The selection process will be initiated and implemented in the war and post-conflict states



4.9.5. Coordination between implementers Describe how coordination will occur between multiple Principal Recipients, and then between the Principal Recipient(s) and key sub-recipients to ensure timely and transparent program performance.

Comment on factors such as:

How Principal Recipients will interact where their work is linked (e.g., a government Principal Recipient is responsible for procurement of pharmaceutical and/or health products, and a non-government Principal Recipient is responsible for service delivery to, for example, hard to reach groups through non-public systems); and

The extent to which partners will support program implementation (e.g., by providing management or technical assistance in addition to any assistance requested to be funded through this proposal, if relevant).

The coordination between the principal recipient and the key sub-recipients is emphasized to ensure the progress of implementation and maximum utilization of the resources. The channels of coordination can take many forms including joint technical taskforce, implementation of joint activities, conduct of joint monitoring and evaluation activities especially at the state and the locality levels. The partnership between the NTP and the NGOs and civil society organization in the war-affected and the post-conflict states is a good model for coordination that if proved success can be expanded to other states. Continuous review of the planned activities in order to identify the potential areas for coordination between implementers can prove to be successful. Some of the sub-recipients have good training resources which can be used to provide technical assistance for the others i.e. Epi-Lab.

4.9.6. Strengthening implementation capacity The Global Fund encourages in-country efforts to strengthen government, non-government and community-based implementation capacity.

If this proposal is requesting funding for management and/ or technical assistance to ensure strong program performance, summarize:

(a) the assistance that is planned;**

(b) the process used to identify needs within the various sectors;

(c) how the assistance will be obtained on competitive, transparent terms; and

(d) the process that will be used to evaluate the effectiveness of that assistance, and make adjustments to maintain a high standard of support.

** (e.g., where the applicant has nominated a second Principal Recipient which requires capacity development to fulfill its role; or where community systems strengthening is identified as a "gap" in achieving national targets, and organizational/management assistance is required to support increased service delivery.)

The technical assistance planned to ensure strong SNTP and NGOs performance is needed in the implementation of the following activities:

Conduct of the needs assessment in the war-affected and the post-conflict areas.

Development and finalization of the national guidelines for DOTS in emergency situation.

The Formulation and finalization of the national policy document for TB control

Establishment of quality assurance program for smear microscopy culture and DST

Capacity building on management, monitoring, evaluation and supervision of the NTB and the TB states units

Conduct of the national drug resistance survey.



Development and finalization of the TB contact management guidelines & training manual.

Implementation of the income-generating schemes

Capacity building of the SNTP staff, the state coordinators, NGOs officials, women and youth leaders on advocacy.

The process used to identify needs within the various sectors:

Field visits to the war-affected and post-conflict areas.

Review of the supervisory, monitoring and evaluation reports.

Interviews with the key informants, NGOs officials, civil society members and TB patients, and TB Patients associations.

How the assistance will be obtained on competitive, transparent terms?

Specific terms of references for the required consultancies will be developed and advertised. Then all the potential applicants are expected to submit their CVs and documents to an independent selection committee which is expected to select the qualified consultant through a competitive process.

The process that will be used to evaluate the effectiveness of that assistance, and make adjustments to maintain a high standard of support.

The terms of references should be clearly stated and discussed firstly at the program level and with the nominated consultant.

Regular reporting to the concerned body in order to facilitate the technical support process and to introduce any needed modifications as early as possible.

Feed-back reports from the beneficiaries.

Submission of final consultancy report with specific recommendations.

Regular monitoring of the implementation of the recommendations by the SNTP.

4.10.1. Scope of Round 8 proposal

No Go to s.4B if relevant, or direct to s.5. Does this proposal seek funding for any

pharmaceutical and/or health products? X Yes Continue on to answer s.4.10.2.



Clarified Table 4.10.2.

4.10.2. Table of roles and responsibilities

Provide as complete details as possible. (e.g., the Ministry of Health may be the organization responsible for the ‘Coordination’ activity, and their ‘role’ is Principal Recipient in this proposal). If a function will be outsourced, identify this in the second column and provide the name of the planned outsourced provider.

Activity

Which organizations and/or departments are responsible for this function? (Identify if Ministry of Health, or Department of Disease Control, or Ministry of Finance, or non-governmental partner, or technical partner.)

In this proposal what is the role of the organization responsible for this function? (Identify if Principal Recipient, sub-recipient, Procurement Agent, Storage Agent, Supply Management Agent, etc.)

Does this proposal request funding for additional staff or technical assistance

Procurement policies & systems

UNDP PR Yes

No

Intellectual property rights FMOH SR Yes

No

Quality assurance and quality control

FMOH SR Yes

No

Management and coordination More details required in s.4.10.3.

FMOH/SNTP SR Yes

No

Product selection SNTP/FMOH SR Yes

No

Management Information Systems (MIS)

SNTP/HIS SR Yes

No

Forecasting SNTP/PLANNING SR Yes

No

Procurement and planning SNTP SR Yes

No

Storage and inventory management More details required in s.4.10.4

FMOH/SNTP SR Yes

No

Distribution to other stores and end-users More details required in s.4.10.4

FMOH SR Yes

No



Ensuring rational use and patient safety (pharmacovigilance)

FMOF SR Yes

No

4.10.3. Past management experience

What is the past experience of each organization that will manage the process of procuring, storing and overseeing distribution of pharmaceutical and health products?

Organization Name PR, sub-

recipient, or agent?

Total value procured during last financial year

(Same currency as on cover of proposal)

UNDP PR 857,952

[use the "Tab" key to add extra rows if more than four organizations will be involved in the management of this work]

4.10.4. Alignment with existing systems Describe the extent to which this proposal uses existing country systems for the management of the additional pharmaceutical and health product activities that are planned, including pharmacovigilance systems. If existing systems are not used, explain why.

The current country system of the pharmaceutical and health products of the Central Medical Stores will be used to effectively distribute the anti-TB drugs to the TBMUs at different level. The system is well-established, efficiently functioning and covering all the states. It is cost/effective to use the existing distribution system rather to develop a separate distribution system. The presence of stores at the state and locality level can facilitate the delivery and ensure safety of the drugs.

4.10.5. Storage and distribution systems

X Sub-contracted national organization(s) (specify) Central Medical Stores

Sub-contracted international organization(s) (specify)

(a) Which organization(s) have primary responsibility to provide storage and distribution services under this proposal?

Other: (specify)

(b) For storage partners, what is each organization's current storage capacity for pharmaceutical and health products? If this proposal represents a significant change in the volume of products to be stored, estimate the relative change in percent, and explain what plans are in place to ensure increased capacity.

Storage of anti-TB drugs and other related health products at the central and at state’s level is shouldered by the Central Medical Stores (CMS) and the drug revolving fund (DRF) respectively. The central medical stores is characterized with it huge storage capacity. Anti-TB drugs, reagents, and equipments are sharing the same store with other health products belonging to the CMS and other programs, which use to create some difficulties in finding spaces for new consignment. Although this problem was not hampering the storage capacity of the SNTP, but recently the CMS started in building new stores. The CMS agreed on providing

r

r



the SNTP a separate new store, which will allow storage of increased requirements.

At the states’ level, the revolving fund (DRF) has established standard stores at different states. Moreover, DRF has medium-size stores at the level of localities. The current overall storage capacity is adequate to accommodate for extra volume of the pharmaceutical products at different levels. .

(c) For distribution partners, what is each organization's current distribution capacity for pharmaceutical and health products? If this proposal represents a significant change in the volume of products to be distributed or the area(s) where distribution will occur, estimate the relative change in percent, and explain what plans are in place to ensure increased capacity.

Anti-TB drugs and laboratory supplies from external donations used to reach Sudan through two inlets: Port Sudan (seaport) and Khartoum (airport). The Directorate General of Pharmacy at the Federal Ministry of Health is responsible for clearance and delivery of these good to the CMS in Khartoum. The clearance process to CMS usually takes about one month in the case of seaport consignments and less than 10 days in the case of airport consignments.

The distribution system from CMS to different states is facilitated by the drug revolving fund. SNTP reached an agreement with DRF that they shoulder the responsibility for drug distribution to states within its distribution jurisdictions. Quantities of drugs to each state depend on the case finding of the previous quarter. The SNTP drug management officer uses a standard IUATLD dispatch form to calculate drug needs for each state. Dispatch of drugs occurs on a quarterly basis. An agent of the DRF for each state collects and prepares the drugs for transport to their respective state.

After reaching their destinations the drugs are stored at the DRF state’s central store. The TB state coordinator and the director of DRF are the responsible bodies for the drugs. The TB state coordinator is responsible of calculating the drug needs for each TBMU in his/her state based on the previous quarter report of case finding. The DRF has pharmacies in almost all the TBMUs. The DRF is responsible for transporting and distributing anti-TB drugs to these centers. For health facilities not yet covered by the DRF, medical directors of these centers are responsible of transporting anti-TB drugs to their units.

The current distribution system is in place and the drug revolving fund fully covers all the TBMUs across the country. The anticipated increase in the volume of drug supplies is expected to be accommodated smoothly by the current distribution system.

4.10.6. Pharmaceutical and health products for initial two years

Complete 'Attachment B-Tuberculosis' to this Proposal Form, to list all of the pharmaceutical and health products that are requested to be funded through this proposal.

Also include the expected costs per unit, and information on the existing 'Standard Treatment Guidelines ('STGs'). However, if the pharmaceutical products included in ‘Attachment B-Tuberculosis’ are not included in the current national, institutional or World Health Organization STGs, or Essential Medicines Lists ('EMLs'), describe below the STGs that are planned to be utilized, and the rationale for their use.

NA



4.10.7. Multi-drug-resistant tuberculosis

x Yes In the budget, include USD 50,000 per year over the full proposal term to contribute to the costs of Green Light Committee Secretariat support services. Is the provision of treatment of multi-drug-

resistant tuberculosis included in this tuberculosis proposal?

No

Do not include these costs



Clarified Table 5.1. 5. FUNDING REQUEST 5.1. Financial gap analysis - Tuberculosis Summary Information provided in the table below should be explained further in sections 5.1.1 – 5.1.3 below.

Financial gap analysis (same currency as identified on proposal coversheet)

Note Adjust headings (as necessary) in tables from calendar years to financial years (e.g., FY ending 2007; etc) to align with national planning and fiscal periods

Actual Planned Estimated

2006 2007 2008 2009 2010 2011 2012 2013

Tuberculosis program funding needs to deliver comprehensive diagnosis, treatment and care and support services to target populations

Line A Provide annual amounts 3911374 11159811 9011553 9555196 10039994 9191846 10543736 6086608

Line A.1 Total need over length of Round 8 Funding Request (combined total need over Round 8 proposal term)

Current and future resources to meet financial need

Domestic source B1: Loans and debt relief (provide name of source )

0 0 0 0 0 0 0 0 Domestic source B2

National funding resources 1,522,909 1,990,688 1,341,804 1,408,894 1,479,339 1,627,273 1,990,688 1,341,804 Domestic source B3

Private Sector contributions (national)

0 0 0 0 0

Total of Line B entries Total current & planned DOMESTIC

(including debt relief) resources: 1,522,909 1,990,688 1,341,804 1,408,894 1,479,339 1,627,273 1,990,688 1,341,804

External source C 1 (provide source name)

108,769 108,769 108,769 115000 135000 135000 135000 135000 External source C2

(provide source name) 108,769 108,769 108,769 101000 121000 121000 121000 121000

External source C3 Private Sector contributions

(International)

0 0 0 0 0



Financial gap analysis (same currency as identified on proposal coversheet)

Note Adjust headings (as necessary) in tables from calendar years to financial years (e.g., FY ending 2007; etc) to align with national planning and fiscal periods

Actual Planned Estimated

2006 2007 2008 2009 2010 2011 2012 2013

Total of Line C entries Total current & planned EXTERNAL (non-

Global Fund grant) resources: 217,538 217,538 217,538 216,000 256,000 256,000 256,000 256,000

Line D: Annual value of all existing Global Fund grants for same

disease: Include unsigned ‘Phase 2’ amounts as “planned” amounts in

relevant years 0 4,019,309 2,810,704 3,087,658 2,614,617 2,878,180 0 0

Line E Total current and planned resources (i.e. Line E = Line B total

+

Line C total + Lind D Total) 1,740,447 6,227,535 4,370,046 4,712,552 4,349,956 4,761,453 2,246,688 1,597,804

Calculation of gap in financial resources and summary of total funding requested in Round 8 (to be supported by detailed budget)

Line F Total funding gap (i.e. Line F = Line A – Line E) 2,170,927 4,932,276 4,641,507 4,842,644 5,690,038 4,430,393 8,297,048 4,488,804

Line G = Round 8 tuberculosis funding request (same amount as requested in table 5.3 for this disease) 4,016,674 4,700,128 4,849,838 4,809,421 4,737,055



Part H – 'Cost Sharing' calculation for Lower-middle income and Upper-middle income applicants

In Round 8, the total maximum funding request for tuberculosis in Line G is:

(a) For Lower-Middle income countries, an amount that results in the Global Fund's overall contribution (all grants) to the national program reaching not more than 65% of the national disease program funding needs over the proposal term; and

(b) For Upper-Middle income countries, an amount that results in the Global Fund overall contribution (all grants) to the national program reaching not more than 35% of the national disease program funding needs over the proposal term.

Line H Cost Sharing calculation as a percentage (%) of overall funding from Global Fund

Cost sharing = (Total of Line D entries over 2009-2013 period + Line G Total) X 100

Line A.1

%



5.1.1. Explanation of financial needs – LINE A in table 5.1

Explain how the annual amounts were:

developed (e.g., through costed national strategies, a Medium Term Expenditure Framework [MTEF], or other basis); and

budgeted in a way that ensues that government, non-government and community needs were included to ensure fully implementation of country's tuberculosis program and strategy.

Financial needs were estimated based on the budget of SNTP with some adaptation to the existing situation in term of the real cost and the absorptive capacity of the program. WHO budgeting template was used for costing the real needs.

5.1.2. Domestic funding – 'LINE B' entries in table 5.1

Explain the processes used in country to:

prioritize domestic financial contributions to the national tuberculosis program (including HIPC [Heavily Indebted Poor Country] and other debt relief, and grant or loan funds that are contributed through the national budget); and

ensure that domestic resources are utilized efficiently, transparently and equitably, to help implement treatment, diagnosis, care and support strategy at the national, sub-national and community levels.

Domestic financial contribution targeting TB control mainly support infrastructure and staff cost. Approved Federal and state Governments annual budget include the submitted need for the TB services at different levels. Through the Government financial system payment for TB is ensured. At state level TB support is either from state contribution or from transferred federal support.

5.1.3. External funding excluding Global Fund – 'LINE C' entries in table 5.1

Explain any changes in contributions anticipated over the proposal term (and the reason for any identified reductions in external resources over time). Any current delays in accessing the external funding identified in table 5.1 should be explained (including the reason for the delay, and plans to resolve the issue(s)).

NA

5.2. Detailed Budget Suggested steps in budget completion: 1. Submit a detailed proposal budget in Microsoft Excel format as a clearly numbered annex.

Wherever possible, use the same numbering for budget line items as the program description.

FOR GUIDANCE ON THE LEVEL OF DETAIL REQUIRED (or to use a template if there is no existing in-country detailed budgeting framework) refer to the budget information available at the following link: http://www.theglobalfund.org/en/apply/call8/single/#budget

2. Ensure the detailed budget is consistent with the detailed workplan of program activities. 3. From that detailed budget, prepare a 'Summary by Objective and Service Delivery Area'

(s.5.3.)



4. From the same detailed budget, prepare a 'Summary by Cost Category' (s.5.4.) 5. Do not include any CCM or Sub-CCM operating costs in Round 8. This support is now available

through a separate application for funding made direct to the Global Fund (and not funded through grant funds). The application is available at: http://www.theglobalfund.org/en/apply/mechanisms/guidelines/



5.3. Summary of detailed budget by objective and service delivery area

5.4

Objective Number

Service delivery area (Use the same numbering as in program description in s.4.5.1.)


1 SDA 1.1 DOTS Expansion in war affected areas 389,499 369,895 231,395 231,395 231,395 1,453,579

2 SDA 2.1 Improve diagnosis : Case detection through quality assured microscopy 1,523,560 925,457 2,036,359 2,000,108 1,936,781 8,422,265

2 SDA 2.2 Monitoring and Evaluation 167,800 1,532,160 315,354 315,354 315,354 2,646,022

3 SDA 3.1 Establish MDR Management 636,000 642,337 1,066,337 1,066,337 1,066,337 4,477,348

3 SDA 3.2 Ensure proper management for household TB contact tracing 64,800 38,400 36,720 36,720 36,720 213,360

4 SDA 4.1 Engagement of other health care providers in DOTS 61,715 91,080 101,080 103,080 105,080 462,035

5 SDA 5.1 Advocacy, Communication and Social Mobilization 505,087 353,131 292,087 292,087 292,087 1,734,478

5 SDA 5.2 Community TB Care 55,500 30,700 30,700 30,700 30,700 178,300

SDA TOTAL 3,403,961 3,983,160 4,110,032 4,075,780 4,014,454 19,587,386

PR Overhead 5% 170,198 199,158 205,502 203,789 200,723 979,369

SR Programme Support Cost (13%)

442,515 517,811 534,304 529,851 521,879 2,546,360

Round 8 tuberculosis funding request: 4,016,674 4,700,128 4,849,837.4 4,809,421 4,737,055 23,113,116



5.4 Summary of detailed budget by cost category (Summary information in this table should be further explained in sections 5.4.1 – 5.4.3 below.)

Clarified Table 5.4. (same currency as on cover sheet of Proposal Form)

Avoid using the "other" category unless necessary – read the Round 8 Guidelines. Year 1 Year 2 Year 3 Year 4 Year 5 Total

Human resources 284,900.0 402,900.0 999,200.0 1,001,200.0 1,003,200.0 3,691,400

Technical and Management Assistance 159,500.0 101,500.0 64,000.0 64,000.0 64,000.0 453,000

Training 250,755.0 278,095.0 145,915.0 145,915.0 145,915.0 966,595

Health products and health equipment 860,175.0 573,450.0 78,112.5 56,475.0 12,187.5 1,580,400

Pharmaceutical products (medicines) - 312,337.0 1,908,952.0 1,908,952.0 1,908,952.0 6,039,193

Procurement and supply management costs -

Infrastructure and other equipment 871,744.0 431,962.0 232,787.0 215,503.0 198,533.5 1,950,530

Communication Materials 384,723.3 220,891.7 220,891.7 220,891.7 220,891.7 1,268,290

Monitoring & Evaluation 479,200.0 1,570,460.0 114,750.0 117,420.0 115,350.0 2,397,180

Living Support to Clients/Target Populations

44,800.0 20,000.0 20,000.0 20,000.0 20,000.0 124,800

Planning and administration 63,364.0 68,364.0 322,224.0 322,224.0 322,224.0 1,098,400

Overheads 4,800.0 3,200.0 3,200.0 3,200.0 3,200.0 17,600

SUB TOTAL 3,403,961 3,983,160 4,110,032 4,075,781 4,014,454 19,587,387.5

PR overhead (5%) 170,198 199,158 205,502 203,789 200,723 979,369 SR Programme Support Cost (13%) 442,515 517,811 534,304 529,851 521,879 2,546,360

Round 8 tuberculosis funding request (Should be the same annual totals as table 5.2)

4,016,674

4,700,128.4

4,849,838

4,809,421

4,737,055 23,113,117


60

5.4.1. Overall budget context

Briefly explain any significant variations in cost categories by year, or significant five year totals for those categories.

NA

5.4.2. Human resources In cases where 'human resources' represents an important share of the budget, summarize: (i) the basis for the budget calculation over the initial two years; (ii) the method of calculating the anticipated costs over years three to five; and (iii) to what extent human resources spending will strengthen service delivery. (Useful information to support the assumptions to be set out in the detailed budget includes: a list of the proposed positions that is consistent with assumptions on hours, salary etc included in the detailed budget; and the proportion (in percentage terms) of time that will be allocated to the work under this proposal.

Attach supporting information as a clearly named and numbered annex

NA

5.4.3. Other large expenditure items

If other 'cost categories' represent important amounts in the summary in table 5.4, (i) explain the basis for the budget calculation of those amounts. Also explain how this contribution is important to implementation of the national tuberculosis program.

Attach supporting information as a clearly named and numbered annex

NA

5.5. Funding requests in the context of a common funding mechanism In this section, common funding mechanism refers to situations where all funding is contributed into a common fund for distribution to implementing partners. Do not complete this section if the country pools, for example, procurement efforts, but all other funding is managed separately.

5.5.1. Operational status of common funding mechanism

Briefly summarize the main features of the common funding mechanism, including the fund's name, objectives, governance structure and key partners.

Attach, as clearly named and numbered annexes to your proposal, the memorandum of understanding, joint Monitoring and Evaluation procedures, the latest annual review, accountability procedures, list of key partners, etc.

5.5.2. Measuring performance

How often is program performance measured by the common funding mechanism? Explain whether program performance influences financial contributions to the common fund.


61

5.5.3 Additionality of Global Fund request

Explain how the funding requested in this proposal (if approved) will contribute to the achievement of outputs and outcomes that would not otherwise have been supported by resources currently or planned to be available to the common funding mechanism.

If the focus of the common fund is broader than the tuberculosis program, applicants must explain the process by which they will ensure that funds requested will contribute towards achieving impact on tuberculosis outcomes during the proposal term.



Section Document description Annex Number

4.1 TB strategic plan 2006 – 2010 1

4.1 Sudan National Tuberculosis Programme Annual Report 2007 2

4.1 THE NEW PROTOCL IN TUBERCLOSIS TREATMENT 3

4.1 Strategic 25 years Health Plan 2002 to 2027 4

4.1 National Health Sector’s Monitoring and Evaluation Framework 5

4.5 PUBLIC-PUBLIC MIX AND PUBLIC-PRIVATE MIX IN TB CARE IN SUDAN

6

4.5 SUDAN NATIONAL TB CONTROL PROGRAM - ACSM - A STRATEGIC APPROACH

7

NB: the checklist for health system is added as separate file, ‘List-Attachments-HSS’



Federal level (FMOH)

States level (SMOH)

Locality level (locality health administration)

Lower level PHC

facilities

Health facilities (State and rural hospitals,

Teaching and specialized hospitals

4B. PROGRAM DESCRIPTION – HSS CROSS-CUTTING INTERVENTIONS

4B. Program description - HSS cross-cutting interventions Refer to the Round 8 Guidelines for more detailed information on health systems strengthening and linkages to the WHO Six Building Blocks for effective, efficient, transparent, equitable, and sustainable health systems.

Sudan health system: an overview Sudan is the largest country in Africa, spreading over 2.5 million square kilometers and administrative divided into 25 states. Northern part, which is focus of this proposal, comprises 15 states, in turn divided into 134 localities or districts (5-12 per state). Total population is 36,297,000, out of which 30,767,000 live in northern states, and 60% is rural. Health indicators are poor and the progress towards achieving MDGs is slow; or at the best stagnant. MMR is 638/ 100,000 live births, IMR is 71/ 1,000 live births, and under-5 mortality rate is 102/ 1,000 live births10. Sudan has 8-11% of TB burden in EMR and annually 1.8% or 28,722 more cases are added. Case detection rate is 35.5%, while cure rate is 52%. For malaria, case fatality is 7%. HIV/AIDS prevalence in people age 15-49 yrs is estimated at 2.3%, while only 1.18%

knew two methods for avoiding transmission.

10 Sudan Household Health Survey, 2006

Type of facility Total

Hospitals, including rural hospitals

357

Urban health centers 558

Rural health centers 458

Dispensaries 1226

Dressing stations 762

OPTIONAL ADDITIONAL SECTION FOR ONE DISEASE IN ROUND 8 GLOBAL FUND PROPOSALS

Copy the material under this text box into the applicant's Round 8 proposal form after s.4.9.7 (for either HIV or Tuberculosis proposals) or after s.4.9.6 (Malaria proposals).

SECTION 4B CAN ONLY BE INCLUDED IN ONE DISEASE IN ROUND 8 and only if:

The applicant has identified gaps and constraints in the health system that have an impact on HIV, tuberculosis and malaria outcomes;

The interventions required to respond to these gaps and constraints are 'cross-cutting' and benefit more than one of the three diseases;

Section 4B is not also included in another disease in the Round 8 proposal;

The applicant is requesting funding for disease interventions (e.g., provision of ARVs to people in need). That is, HSS cross-cutting interventions ARE NOT offering a HSS only component in Round 8; and

The applicant also downloads 'Section 5B' from the Global Fund website and includes it after s.5.5 in the same disease proposal as the applicant has inserted this section 4B.

Read the Round 8 Guidelines to consider including HSS cross-cutting interventions



The country is a decentralized federation. Its health system is organized at three levels: Federal Ministry of Health (FMoH), State Ministries of

Health (SMoH) and Locality Health Authorities (see figure); and have three, but inclusive, levels of care providers. At the apex of health care pyramid are the teaching, general and specialist hospitals; some attached to teaching institutes, have varying number of specialties and beds rendering secondary and tertiary care. Primary care is provided through a variety of outlets: urban and rural health centers, dispensaries, dressing stations and PHC units (see table). In addition to the Ministries of Health, organization like police, army, railways, large banks etc. provide health services to their employees and their dependents. Also, there is a growing private sector that is increasingly capturing the health market.

The geography and ecology contributes to shaping the country’s health, nutrition and population situation. Vast distances and poor roads and transport structure affect coverage. Quite infrequently, droughts and flooding cause humanitarian emergencies and ecological factors expose population to infectious and parasitic diseases including malaria. But, the most important factor that contributed the current shape of the health system was the civil war. Although a Comprehensive Peace Agreement (CPA) was signed in January, 2005 between Government and Sudan Peoples Liberation Movement (SPLM), two decades of war has devastated the social services including health, directly and indirectly. While some areas witnessed war, others suffered due to the effects of war by hosting the displaced people and yet others were affected on account of the diversion of resources meant for development. As a result, while human sufferings have been rife, weak and disrupted health system was not able to respond to the needs, and yet conflict in Dafur continues to further bleed the health system.

Drawing on a number of reviews (Sudan Health Workforce Survey, 2007; Sudan Health Information System: Review and Assessment, 2007; Sudan Household Health Survey, 2006; Sudan Health System Profile, 2006; Government of Sudan and World Bank Joint Assessment Mission, 2005; Sudan Health System Survey, 2004) and benefiting from analysis made in developing GAVI/HSS proposal (October, 2007 Round) and WHO Country Cooperation Strategy (2007), using WHO building blocks’ model, the following picture of health system emerges:

1. Service delivery: Overall, 45-65% of population has access to PHC services, i.e. on average, 1 facility serves 12,000 people. Health facilities are unevenly distributed, resulting in a wide variation in the size of population served by a facility. There are 5.2 hospitals and 246 hospital beds per 100,000 people in Alshimalia State compared to 0.2 hospitals and 14 beds per 100,000 in South Darfur11. While 65% deliveries are attended by trained personnel, 20% occur in health facility, outpatient consultation is 0.8 per capita per year.

The chronic conflict and scarcity of resources led to the poor infrastructure of health facilities, particularly PHC and lack essential maintenance. 29% PHC health facilities, including first level referral rural hospitals are not functional; and this situation, which varies in states, also extends to diagnostic services that are weak and fragmented between programs.

2. Information: A recently conducted assessment indicated a weak health information system (HIS); and a variety of issues facing it12. The data is incomplete and outdated, as a result, it is difficult to install and operate a robust system for monitoring and evaluation. Most of the PHC facilities and the private sector, including NGOs are not covered, while organizations like army, police etc. have their own information system. There are vertical information strands for data production, collection, processing, and reporting by the departments and programs, which due to poor coordination seldom gets consolidated. Such a state of affairs makes it difficult to develop a definitive account of Sudan’s achievements and monitor its progress in many of the inputs and outputs necessary to achieve the MDGs. Surveillance is weak and fragmented, as different programmes have dedicated systems, which poorly integrate with routine HIS.

3. Medical products and technologies: There is a national essential drugs programme that includes the pharmaceutical policy, national essential medicines list, standard treatment guidelines and national drug formulary. However, prescription of medical products is far from being rational. While such a practice causes, inter-alia drug resistance, there is no system to report adverse drug reactions. Recently, a Federal Board for Pharmaceuticals has been established, but is in infancy to effectively regulate the quality of medical products. There is a drug registration system, but quality of medical products in the market is not 11 Sudan Health System Survey, 2004 12 Sudan Health Information System: Review and Assessment, 2007

PHC units 3044

Building blocks combine to meet health system goals

SYSTEM BUILDING BLOCKS

Access

C"",rage

OVERAlL GOAlS I OUTCOMES

Improved health(level and equity)

ResponsivenessMedica' ...ooucts, tec_ogies

Heilllttl workf..-ee

Financing

Leadership I u.-orn""",e

Qualil\l

Finanei'" riskPfolec1ion



fully assured. Drug Quality Control Laboratory is weak in Good Laboratory Practice; and is not pre-qualified by WHO. There is also weak policy and control on pricing of medicine, as certain items cost 18 times the global average; thus limiting access to the medical products, particularly by the poor.

A Central Medical Stores, which is main importer and supplier of drugs, has introduced a revolving drug fund for health facilities. There is a parallel system of procurement, supply and storage of donor funded, e.g. GF medicines. Health facilities are inadequately equipped. While, more than 50% facilities had less than minimally required equipment, there is no policy on health technology; and systems for assessment and management, including repair and maintenance of medical equipment is weak. The services offered at health facilities are, therefore not efficient and are of weak quality.

4. Human resources for health: There has been a massive brain drain, both internally and externally. That is, while the health work force is inadequate, it is inequitably distributed between urban and rural areas – the latter suffering the most, and capital cities and big institutions attracting the many. Workforce information system is inadequate and rudimentary, which limits the capacity of HRH management for taking a timely remedial measure. Career structure is unclear and incentives, including salary structure are weak, and there have been insignificant efforts to retain health workforce within the country and/or for ensuring their deployment in the underserved and rural areas.

Curricula for pre-service training are not updated and the system for accreditation and licensing of institutions is weak. The education institutes continue to use old the disciplinary and body systems’ clinical models that use hypothetical- deductive reasoning, which is typical of backward reasoning approach In-service training is inadequate and not accredited. According to a recent survey (Sudan Health Workforce Survey, 2007) 76% health staff had no training during the past 5 years.

5. Financing of health: the health sector is under funded, and total health expenditure is far short of the recommendations by the Commission on Macroeconomics and Health for achieving MDGs. Sudan, with its GDP per capita of US$ 434 (2004), is a low income (LI) country in sub-Saharan Africa (SSA) region. Its total health expenditure (THE), as %age of GDP was 4.3% in 2003, which is less than average for countries in SSA (5.0%) and LI group (5.2%). Households financed 55% of total expenditure on health through out-of-pocket, exposing many to catastrophe, and pushing them below the poverty line. This compares with an average of 41% in SSA and 47% in the LI group. Sudan is less dependent on donor resources for health than is the average country in the SSA region. Donor spending on health as %age of THE in 2003 was 2%, compared with the SSA average of 16% and LI group average of 19%13.

National Health Insurance Fund provides coverage, mainly to government employees. Informal sector is largely uncovered, and the benefit package and level of co-payment needs revision. While interventions aimed at management development are needed, the feasibility studies, including actuarial and cost effectiveness analysis for ascertaining the possibility of extending coverage have not been undertaken.

6. Governance and leadership: this function is weak at all levels of the health system. While the MOH, has developed health polices and strategies, its ability to translate these into the implementable programs at the state and locality level is limited in designing and setting up systems, e.g. financial, personnel, health information, logistics management systems, as well as support systems, like referral, monitoring and supervision, drug and pharmaceutical supply system, and repair and maintenance. Thus, the current situation poses challenges to the decentralized nature of Sudanese health system. Also it has a limited capacity to build coordination and collaboration with other key government actors in health field (such as Health Insurances, Military and Police health and medical services) and the private sector.

The abovementioned issues seem to be generic, but the Director Generals of Health Services for fifteen Northern States in their meetings on 29-30 March and 28-29 May, 2008 verified these as cross cutting barriers that impact the performance of national health system for a response to the three diseases to achieve MDGs, including MDG-6 for ATM. See outcome of meeting at annex A.

Furthermore, the results of a SWOT analysis of Sudanese health system conduced as part of GAVI/HSS application development, which is also relevant to this application, is given below: a. Strengths

1. There is a clear direction envisioned in the Constitution, 25-year long term and 5-year short term strategic plans, and the national health policy, which is most important strength. All these documents explicitly indicate government’s resolve

b. Weaknesses

1. Core competencies, like health planning, information, management are weak, especially at peripheral level. Thus, there is a risk, particularly with decentralized nature of governance, states and locality might not efficiently exercise authority

13 http://healthsystems2020.healthsystemsdatabase.org



to building health system, based on the principles of comprehensive primary health care.

2. There exists some infrastructure, albeit dilapidated and in many cases unusable. Yet, it provides basis to plan and undertake recovery and development. Many steps required for de novo acquiring and building will not be required, saving time and investment in recovery and development.

3. Although various subsystems at different levels of governance are disrupted, there remains a degree of institutional memory and basic skills, which can contribute to its rebuilding. There is agreement on purpose and principals, components and hierarchy. It is primarily the investment, financial and human, which is awaited.

4. Years of conflict and periodic disasters disrupted and weakened the health system due largely to the public sector spending on health dwindled. This lack of resources was, to some extent, substituted by the communities, as buildings and financial contributions – an attribute that can be exploited to strengthen health system.

and use input for recovery and development of health system, and improve service delivery.

2. Conflicts and continuing under-development caused skilled manpower left country. Disruption of infrastructure in periphery caused internal brain drain and thereby created a vicious circle of mal-distribution of human resources and poorly maintained health infrastructure.

3. Since resources were diverted from social services to conflict and disasters, evolution of systems suffered both at national and sub-national levels. The increasing focus on service delivery and continuing brain drain added to weakening the systems that are essential for sustaining the delivery.

4. Due to displacement of population, there has been a trend for urbanization. To respond to this challenge, focus shifted to urban health services, neglecting rural and hard to reach areas. Clinical services surpassed public health on the priority list and so was the training of health workers, including those delivering programmatic services.

c. Opportunities

1. The CPA ended the civil war and there are signs to reach a deal to end the conflict in the three Darfur states. As a result there is a degree of stability, albeit raising the expectations of people, who want to see the peace dividends. Also a grater attention is being given by the government to the social services, including health services.

2. The international community is committed to work with the government for recovery and development including health services. A JAM after CPA calling for an input of US$ 7.9 billion, out of which US$ 4.3 billion was earmarked for Northern States, including US$ 0.7 billion for the deprived areas, and a major part of it is allocated for the basic social services including health.

3. The national resources are increasingly being committed for health. The Medium Term Expenditure Framework (2008-2011) aims at increasing government expenditure on health from the current level of 1.5% of GDP to 2.15% of GDP by 2011. In addition, a larger share is allocated to states from the national resources.

4. The federal nature and decentralization committed in Constitution provides another window of opportunity. Greater availability of resources complimented by authority for decision making at state and locality level will enhance efficiency, better utilization of resources, and harnessing the potential of communities.

d. Threats

1. Sudan is a vast country with long distances and poor road and transport infrastructure. Such factors have contributed to the inequitable distribution of health infrastructure and thereby poor access to services. In addition, the nomadic nature of population complicates issues surrounding the access to services.

2. The country is prone to natural disasters, like floods and droughts. While these disrupt infrastructure, including that of the health system, also cause illness and bring sufferings for the people, who in many cases get displaced, losing shelter, food and sources of income. Thus posing a greater demand on the already weak and disrupted health system.

3. Health system strengthening is relatively a new concept. Also, there is rather a skewed understanding, and the importance of health system strengthening as a means to improving service delivery. Therefore, professionals hitherto involved in the latter might resist any input for developing health management and organization.

4. Given that the main focus of the Ministries of Health has so far been on humanitarian action and provision of clinical services in urban areas, health system development tilted and disoriented likewise. In the presence of such biases, there might be a competition for resources between different components of the health systems.



Efforts to resolve health system weaknesses and gaps

In addition to the regular input by the government, a number of initiatives have been introduced, but, by no means, are adequate. An overview of these is given as below:

a. Government of National Unity (Northern Sudan): although total health expenditure has been low, the government is committed to increase it investment; and during past 5 years it increased substantially. The budget for FMOH increased 4 folds from US$ 28.46 million in 2000 to US$132.5 million in 2006. In terms of per capita spending on health, FMOH expenditure increased from 0.91 US$ in 2000 to 3.65 US$ in 2006. The same trend is also observed at states level where, on averages, the annual expenditure on health was US$ 4.5 per capita in 2005, compared to US$1 in 2000. However, most of this allocation is used to fund salaries and basic service, leaving little for developmental (infrastructure) and operational expenditure (for day to day operations).

b. Decentralized Health Systems Development (DHSD) Project: based on the findings of a Government of Sudan and World Bank Joint Assessment Mission (2005), in health sector, a DHSD project with a total cost of US$70 million over four years (2007-11) funded jointly by the Government and Multi-Donor Trust Funds (MDTF) by a ratio of 2:1 was launched in January, 2007. This project with a focus on four states (Red Sea, Kassala, Blue Nile and South Kordfan), aims to: (i) expand service delivery on long term, in parallel with ‘quick win’ projects; (ii) develop infrastructure for health care; (iii) provide a system for delivering sustainable health care; and (iv) scale up human resource for health.

c. GAVI/HSS support: consequent to a successful application for October, 2007 round, Sudan will receive US16.2 million over five years (2008-12). The interventions envisaged, which are complementary to DHSD project with a focus on the other four states (Gedarif, White Nile, North Kordofan and Sinnar) aims to address health system barriers by: (i) developing organization and management of decentralized local health system; (ii) building capacities at national, state and district level in health planning and development; (iii) developing human resources for health, including by investing in Academies of Health Sciences; (iv) improving capacities and knowledge base for equitable and sustainable health financing; and (v) strengthen health management information system and monitoring and evaluation.

d. Sudanese Cooperation and Development Project: funded by Italian Ministry of Foreign Affairs with a total of US$ 600,000, this project complements the DHSD project for strengthening PHC by building infrastructure and capacity in the most deprived and remote areas of Kassala and South Kordofan states. But, it is limited, geographically as well as the range of interventions it proposes, and the allocation is too little to address the health system issues, be they at any level of care.

d. Support by Health Metrics Network: with the aim to strengthen health information system, a grant (US$250,000) was received in 2007 for assessing the health information system and devising a plan for its strengthening. The first phase of this project has been completed, and preparations for the next phase are being made. But, given that in recent years there has been a little budget for development, and this situation is likely to continue in the near future, funds will be required for implementing the plan.

e. Collaborative programs of United Nation and NGOs: WHO, UNICEF, UNFPA and others support FMOH for a variety of programs by mainly providing technical assistance and capacity building. In addition, country being disaster prone, both natural and man-made, these agencies are involved in providing humanitarian assistance for emergency preparedness and recovery measures with a particular focus on the three Darfur states as well as Kassala, Blue Nile and South Kordofan states.

NGOs has been vital for health sector; and over 85 national and international NGOs operate in Northern Sudan and other 65 in Darfur. These are active in humanitarian assistance, providing support in emergency relief rehabilitation, education, orphan sponsorships, mother and child cares, health services, environment, supply of water and sanitation among other development activities. In addition, there are few more working in Eastern Kassala State and the Three Areas (South Kordofan, Blue Nile and Abyei).

f. Global Fund to fight AIDS, Tuberculosis and Malaria: country launched five successful applications: rounds 3 and 5 for HIV/AIDS; 2 and 7 for malaria; and 5 for tuberculosis. Total resource envelope of these grants adds up to US$ 276,649 million, and so far country has so far received US$51,861 million.

Successful HIV/AIDS applications, both for round 3 and 5, focus on programmatic issues, mainly scaling up interventions for the prevention and treatment of HIV/AIDS. Likewise, malaria application for round 2 aimed at improving the programme performance to reduce malaria burden, while application for round 7 includes health systems component, albeit in support of National Malaria Programme. Medicine stores at the national, state and locality levels will be constructed and equipped. Also, procurement and supplies management system will be developed.



But, still there are gaps in meeting many of the health system challenges:

These exist in all the health system building blocks, for all levels of care (primary, secondary and tertiary), at all levels of governance (national, state, and locality), and in all geographical regions of the country; and these challenges are more sever and worsen further at lower levels, i.e. primary and secondary care and at the locality level. To respond to these continuing challenges that mar health system’s response to the three diseases, the technical working group, appointed to develop HSS component of the application for GF-Round 8, in their successive meetings and the Director Generals of Health Services for fifteen Northern States in their meetings on 29-30 March agreed on the following goal and strategic actions: The overall goal for GF Round 8 application: To improve the performance of national health system for a better response to the three diseases to achieve MDGs, including MDG-6 for ATM.

Within the remits of this goal, the following objectives or interventions/strategic actions are identified:

1. Improve health services delivery including laboratory services, assuring quality and equity of access at all levels of health care

2. Strengthen health management information system, including surveillance and setting up a M&E system for measuring the health system’s performance

3. Build capacity of the system for drugs, supplies and equipment procurement and management, including quality assurance

4. Scale up, quantitatively and qualitatively, the availability of HRH at different levels of health care that it matches the basic standards

5. Strengthen health financing function for assuring equity and access to health service



4B.1 Description of 'HSS cross-cutting intervention'

Refer to the Round 8 Guidelines for information completing this section.

Title: Intervention 1 (Change number for each intervention)

Improve health services delivery including laboratory services, assuring quality and equity of access at all levels of health care

Beneficiary Diseases: (e.g., HIV, tuberculosis,

and malaria?) Cross-cutting (for all three disease)

WHO "Building Block" category

(Refer to the Round 8 Guidelines)

Service delivery

(a) Description of rationale for and linkages to improved/increased outcomes in respect of HIV, tuberculosis and/or malaria:

MAXIMUM ONE PAGE FOR EACH ACTION

Background and relevance: a SWOT analysis of health service delivery (see above) revealed the infrastructure, particularly of PHC facilities, which hosts different programs including the three diseases and laboratory services, is dilapidated and lack essential equipment and furniture14.

The National Constitution (2005) commits the state to provide free primary health care and emergency services to all its citizens, with particular attention to the poor and underserved. The NHP, reiterating this resolve (s8.2.1), proposes to achieve this by rehabilitating, re-equipping and refurbishing the infrastructure (s8.2.2) and assuring quality of health care (s6.3). In 5-year Strategic Plan for Health Sector, these directives are translated into strategic actions (SO 3 and 4) with a goal to improving coverage and accessibility to quality health services. Within these remits, the TWG and DGHS defined following objective for this component of the proposal that was later endorsed by the CCM.

1. Objective: improve health services delivery, including laboratory services at all levels, assuring quality and equity. In order to achieve this objective, following activities are envisaged:

1.1. Support organization and management of state and localities levels, which is essential to build capacity and effectively operate the decentralized health system. Sudan is a decentralized federation, as assured by Constitution. From GAVI/HSS support, it is planned to support 15 state health management teams and 20 locality health management teams, charged to manage, supervise and plan health services, including for the three diseases. Such team, by bringing public representative, will be a forum to involve communities in the management of health services.

Complementing the GAVI/HSS (2008-12) input, this proposal will support remaining 114 localities in developing and building the capacity of locality health management teams to strengthen them as an organization at grass root level. The initiative will include developing protocols for teams and orientating them on decision-making, teamwork, and conducting effective meetings. Also, essential office equipment (4 states and 134 locality teams) will be provided to improve work environment and to effectively discharge their functions.

1.2. Integrate programmes with the mainstream health care services: At present, there is an array of programs, including for the three diseases. These programs sit in the mainstream health care, but follow their own managerial and service delivery process. Therefore, while such programmes have been successful in eradicating and or reducing the burden of specific diseases, often these create duplication and place too much demand on the health services. Furthermore, since programs require their own clinical/technical and managerial bureaucracies, information requirements and supplies system, are often inefficient, particularly in facility utilization, as these are less likely to deal with co-morbidities, including those associated with the three diseases.

Therefore, this proposal will support TA for the review of the service package for the different levels of health vis-à-vis programs, including for the three diseases, and revise it, incorporating the latter into the former. Assistance will be given to implement this initiative in two selected pilot states that all health facilities at all levels of care provide an integrated package; thus enhancing the coverage and access of people to services, including for the three diseases.

1.3. Improve physical infrastructure: A significant number of facilities are ill maintained, lack essential equipment and supplies (ibid), thus compromising access and quality of health care, including for the three diseases. GAVI/HSS, considering the importance of health care infrastructure in sustainable service delivery, provided grant to rehabilitate and refurbish health facilities in the four states.

To compliment the GAVI/HSS input, while government will rehabilitate the facilities, this proposal seek their re-equipping and refurbishing, enabling them to render health services, including for the three diseases. This activity,

14 Sudan Health System Survey, 2004



which will make the health facilities functional, will be catalytic in improving access and quality of care to the people.

1.4. Improve laboratory services: These services are meant to: screen, confirm diagnosis, and manage and care the client, including for the three diseases. In Sudan, these services are part of health care network, although certain programs organize and operate them vertically. Given that, as indicated above, health care infrastructure is weak, the laboratories are no exception. The blood banks are part of laboratory, except in tertiary hospitals, and play important role in screening blood, particularly for HIV/AIDS. This issue, compounded by long distances and poor roads and transport system, contributes to the barriers of access and quality of health care, including the three diseases. Due, most likely, to this factor, case detection rate for tuberculosis has been stagnant, if not deteriorated.

Therefore, while program specific laboratory services will integrate (activity 1.2) with mainstream health care, and will be rehabilitated and refurbished (activity 1.3), this activity aims to develop the organization and management of laboratory services that these are available at different levels of care to support diagnosis of the three diseases. As a part of this initiative, laboratory recording and reporting system will be strengthened and integrated with the routine HMIS. Selected laboratories at different levels of care will be strengthened to act as a referral and to institute quality checks on the procedures performed at lower levels and build capacity of human resource for laboratory.

1.5. Community and home based health care: is important component of health care, particularly in the context of Sudan, which has its 60% of its population living in rural and hard to reach areas, and many of them nomads, for whom health care is scarce if nonexistent, essentially due to the paucity of health workforce. In such a situation, in resource-limited settings, like Sudan WHO advocated community and home-based care (CHBC) for people living with HIV/AIDS (PLWHA) and those with chronic or disabling conditions, e.g. Tuberculosis to provide them high-quality and appropriate care to maintain their independence and achieve best possible quality of life15.

Through this proposal, CHBC approach, using WHO framework and learning from the experience of South Africa and Ethiopia, will be piloted in two states (North Kordofan and Red Sea). CHBC package, which will include preventive, promotive, therapeutic, rehabilitative, long term maintenance and palliative care, will serve cases of malaria, DOT for TB and PLWHA by a new cadre of community health volunteers in the community supported by the community health workers at the health facilities. After training they will be given a simple treatment/information kit. NB: see also section on HRH under intervention 4 .

(b) Indicate below the planned outputs/outcomes (through a key phrase and not a detailed description) that will be achieved on an annual basis from support for this HSS cross-cutting intervention during the proposal term. Read the Round 8 Guidelines for further information.

Year 1 Year 2 Year 3 Year 4 Year 5

1.1.1: locality health management teams organized and trained in 21 localities

1.1.2: 4 state health management teams receive essential office equipment

1.1.4: 4 state health management teams receive vehicle to improve supervision


1.1.3: locality health management teams (45) receive essential office equipment

1.1.5: 10 locality health management teams receive vehicle to improve supervision

1.1.6: admin and accounts staff trained in 4 states and 45 localities (2 from each * 5 days)




1.1.6: admin and accounts staff trained in 24 localities (2 from each * 5 days)









1.2.1: framework developed for an integrated health service package

1.2.2: service package and job descriptions revised

1.2.3: integrated package of health services piloted in 2 pilot states

1.2.3: piloting of integrated health services …continues

1.2.4: the integrated health service pilot is evaluated and plan for replication developed (TA + workshop +

15 WHO (2002) Community home-based care in resource-limited settings: a framework for action



fieldwork + report)

1.3.1: investment plan prepared for health care delivery network

1.3.2: essential equipment and furniture provided to 5 Rural Hospitals

1.3.3: essential equipment and furniture provided to 25 PHC facilities







---

1.4.1: 15 Rural Hospital laboratories upgraded as referral

1.4.3: 4 State Hospital laboratories upgraded as referral


1.4.2: 40 PHC lab technicians receive refresher training


1.4.4: 20 Rural hospital lab technicians receive refresher training









1.5.1: framework for community and home-based care developed

1.5.2: package for community and home-based care developed

1.5.3: master plan developed for recruitment, training and deployment of community health volunteers

1.5.4: community and home-based care initiative implemented in 2 states – 200 CHVs recruited and deployed

1.5.5: Kits provided to trained 200 CHVs

1.5.4: community and home-based care implemented in 2 states – 200 CHVs recruited and deployed


1.5.4: community and home-based care implemented in 2 states – 200 CHVs recruited and deployed


1.5.6: pilot for community and home-based care evaluated

(c) Describe below other current and planned support for this action over the proposal term

In the left hand column below, please identify the name of other providers of HSS strategic action support. In the other columns, please provide information on the type of outputs.

Name of supporting stakeholder

Timeframe of support for HSS action

Level of financial support provided over proposal

term (same currency as on face sheet of Proposal Form)

Expected outcomes from this support

Government (FMOH) 2008-9 128,000,000 Rehabilitation of Rural hospitals

Other Global Fund Grants (with HSS elements (Malaria R7)

2008-12

1,776,394

Improve the storage capacity at locality level

Provision of basic equipment to dispensaries

Other: WHO

2008-9

97,000

An integrated and comprehensive PHC approach developed in 12 northern states



Other: UNICEF 2008

9,245,361

Access to basic quality health and nutrition services improved at all levels of health care

Other: UNFPA

2008 1,064,370 Essential Safe Reproductive Health package provided

Other: GAVI/ HSS 2008-2012 7,206,000 Contribute to improving EPI coverage in the northern states by increasing fixed sites in the four northern states

Contribute to achieving equitable coverage and access to quality PHC services for maternal health and child survival in the 4 northern states

Other: MDTF/DHSD 2007-2011 14,500,000 Improve access to primary health care services and high-impact health interventions in four states of Red Sea, Kassala, Blue Nile, and South Kordofan

Other: ITALIAN COOPERATION

2008-9 600,000 Improve access to primary health care services and high-impact health interventions in South Kordofan

Other: ISLAMIC DEVELOPMENT BANK

2008-2010 13,600,000 Rehabilitation/ expansion of infrastructure of state hospitals in three states






Strengthen health management information system, including surveillance and setting up a M&E system for measuring the health system’s performance





Information



Background and relevance: the current status of health information system (HIS) was briefly given above. It comprises subsystems, namely: household and other population based surveys; registration of vital events and census; patients’ records and routine health information system; disease surveillance and outbreak notification; programme specific monitoring and evaluation; and administration and resource management.

In Sudan, studies (e.g. DHS, 1987; Safe Motherhood Survey, 1999; MICS, 2000; and a Household Health Survey in 2006 to provide baseline data for MDGs) have been undertaken, but are limited geographically or methodologically in that these do not cover all aspects of the health system. A national census has concluded in May, 2008 and results are likely to be available in early 2009. The system for the registration of deaths and birth is in its infancy that only 58% births were recorded16, while there exists no organized system for recording deaths and their causes. Data about patients and diseases is collected at PHC facilities and is submitted monthly to locality health management, where it is computerized, although many localities continue to employ manual systems, for transmission on a diskette or manually generated sheets to the SMOH. Here a quarterly report is prepared for submission on a diskette to National Health Information Centre (NHIC) in FMOH, which generates a yearly report on selected indicators, e.g. coverage, timeliness of reports, ten causes of attendance, no. of patients by sex and age, and no. of births and type of delivery. The secondary and tertiary health facilities have better recording and reporting of health information. Private sector is not covered, while organizations like, army, police, banks etc. providing health care to its employee have their own information system with no link to the health information system. The surveillance of communicable disease of public health concern is done by the Directorate of Epidemiology. Vertical programs, e.g. HIV/AIDS, EPI, TB, and Malaria etc. have program specific information systems, which coordinate weakly with NHIC.

Such a gave picture of HIS and therefore deficient information, whether qualitatively or quantitatively hinders the effective management of health services, including the three diseases. Therefore, National Health Policy, 2007 (NHP) emphasizes on the designing and implementing of a comprehensive health management information system (HMIS), also bringing in the private sector (s7.2 and s8.1.6). This resolve is also reiterated in the strategic objective 1 of the 5-Year Strategic Plan for Health Sector.

2. Objective: Accordingly, the overall objective of this component of the proposal is to strengthen HMIS including surveillance and setting up a M&E system for measuring the health system’s performance (meeting of state DGHS, 29-30 March, 2008). In order to achieve this objective, the following activities will be undertaken:

2.1. Improving the existing HMIS, integrating the programme specific information and surveillance system, and to cater, in addition to health services statistics, data on stocks, human resources etc both in public as well as private sector. For this purpose, an integrated, comprehensive information base (CIB) will be developed at federal, state and locality level to receive and or collect data, transform it into a general framework for integration, compilation and analysis, based on the indicators including those for the three disease, and to generate and disseminate reports.

In order to carry out the above, GAVI/HSS funds are available to provide TA for the identification and definition of indicators, development of a national data dictionary, standards for regulating data transfer/exchange to and from database at different levels, and a uniform coding and classification system and procedures for data cleansing, feeding and processing and designing of algorithms for linking data from various sources to establish a record linkages. These measures are aimed at improving the quality of data, implying it is timely, precise, and complete.

To compliment input from GAVI/HSS that focuses at national and state levels, GF support will be used to extend the initiative to locality and facility levels; and to develop, through consensus, the HIS data tools, i.e. forms, registers and

16 Household Health Survey, 2006



report formats. Funds will be needed for the procurement of hardware, i.e. servers for the federal and state level and desk top computers for the state and locality health information centers, purchase/development of software, printed supplies, and training of health staff in using the new system, including data collection tools. Also, long term and short term TA and operational cost will be required to coordinate the designing and implementation of the new HMIS.

2.2. Monitoring and evaluation (M&E) is crucial for the efficient and effective management at all levels: national, state and locality and to report health system’s performance against the parameters defined in the NHP and 5-years Strategic Plan, including for the three diseases and measure the country’s progress towards MDGs. Setting up such a system will require data, in addition to that held on CIB, collected through periodic surveys for an agreed set of indicators. The MOH has developed a document, using 5-year Strategic Plan for Health Sector as reference, for monitoring the implementation of strategies on a set of indictors agreed by all stakeholders. While much of the information will be available through the routine HMIS, periodic surveys will be required to fill in the data gap.

Through GAVI/HSS support TA will be provided for setting up a M&E system at the federal and state levels. Under this proposal, to compliment input from GAVI/HSS, which is inadequate, funds are required to operationalise the M&E system, including for organizing surveys to collect information that is not available through routine HMIS. In addition, key M&E staff will be trained to build their capacity for reporting on health system’s performance.

2.3. Health system observatory will be developed at national level in Secretariat for Planning, Policy and Research, and it will later be linked with EMR observatory17. This observatory, as an organ of the Sudan health system will report on the health statistics, including for the three diseases, disaggregated by states, gender and age:

draw on the information base (see above) at national level; the basic idea being to establish a national electronic resource center to hold a database on selected indicators, and to develop on standardized templates health system profiles, in a phased manner, for the national, state and localities.

integrate the descriptive and disease surveillance data with the attribute and spatial data for states and localities, available with WHO and other UN agencies, using GIS software to generate yearly Sudan health statistics report and maps, including for the three diseases.

include a centre or e-health library for knowledge management, documentation and promotion of research on health system issues, including those for the three disease. This centre will archive technical documents and published material and will serve as a data bank for health statistics for all levels of the health system



2.1.1: framework for integrated HMIS developed

2.1.2: list of indicators reviewed and developed

2.1.3: data collection tools reviewed/developed

2.1.4: national data dictionary developed

2.1.5: training material for facility staff developed

2.1.6: health facility staff (25 localities) trained in using HMIS tools

2.1.7: IT equipment provided to NHIC, 15 State HIC

2.1.8: IT equipment provided to 25 locality health information units

2.1.9: printed supplies provided to health facilities in 25 localities

2.1.6: health facility staff (in 75 localities) trained in using HMIS tools

2.1.8: IT equipment provided to (75) locality health information units


2.1.6: health facility staff (in 34 localities) trained in using HMIS tools

2.1.8: IT equipment provided to (34) locality health information units


2.2.1: surveys designed for collecting data, not available in routine reporting

2.2.1: fieldwork done and data analysis completed

2.2.2: fellowships (15 man-months) granted to M&E staff at federal level

2.2.1: M&E report on national health system performance published

2.2.2: fellowships (21 man-months) granted to M&E staff at state (7) level


2.2.2: fellowships (24 man-months) granted to M&E staff at state (8) level


17 gis.emro.who.int/HealthSystemObservatory



2.3.1: e-health systems' observatory designed

2.3.2: data bank on health statistics developed

2.3.3: a web based template for health systems profile developed

2.3.4: Sudan health systems' profile available online and linked to WHO-EMR health system observatory










Government

2008 100,000

Provide registration formats and books for reporting health facilities

Two basic training courses for statistical technicians

Other Global Fund Grants (with HSS elements (if applicable)

Other: GAVI HSS 2008-2012 895,000 Support designing and implementing a community based health information system

Designing a comprehensive integrated information base at national and state level

Other: MDTF/DHSD 2008- 2011 220,000 TA to support implementing M&E system in the 4 state of Red Sea, Kassala, Blue Nile, and South Kordofan

Other: HMN 2007-09 250,000 To review the health information system and develop a comprehensive plan for improvement






Build capacity of the system for drugs, supplies and equipment procurement and management, including quality assurance





Medical products and other health technologies



Background and relevance: health technology include “the devices, drugs, medical and surgical procedures – and the knowledge associated with these – used in the prevention, diagnosis and treatment of diseases as well as in rehabilitation, and the organizational and supportive systems within which the care is provided” 18; and as reported by WHO, treatment with medicine accounts for 20-40% of health budget in developing countries19. But, the sustained availability of medicines and appropriate technologies at health facilities contributes to their better utilization and building the confidence of users in the quality of health services, including for the three diseases.

A broader picture of the status of this building block of health system in Sudan was given above. It indicted the shortfalls that impact the outcome of health services, including for the three diseases. This is a cross-cutting issue underlined in NHP (s8.1.7 and s8.1.8) and 5-year Strategic Plan (SO 7). Also, in their sessions, the TWG and DGSHS identified these issues, hindering the response of the health system to the three diseases, and to address these, outlined the following objectives and activities to form part of GF/HSS proposal:

3. Objective: improve system for the procurement, storage and supplies and management for medicine and healthcare technologies, including assuring quality for improving health system performance, particularly for a better response to the three diseases. This objective will be achieved through the following sets of activities:

3.1. Procurement policies and systems: for medicines, vaccines and biological is an important element of the health system; and encompasses, inter-alia a range of activities from setting up national polices for the selection of drugs to the procurement and supplies/stores management, including management information system (MIS). Through GFR 7 for Malaria, support is given to refurbish stores and improve procurement, supplies and distribution of free and donor funded drugs, and designing/adapting of guidelines for Good Storage and Distribution Practices.

This proposal, complimenting input from GFR 7 for Malaria, will support the setting up of polices for the selection of drugs, i.e. national drugs policies, essential drugs list and formulary for the different levels of care. A unified procurement, storage and distribution of drugs is an issue between a semi-autonomous Central Medical Stores and for the donor funded drugs and supplies. Mechanisms will be developed, with consensus of stakeholders, for the two systems to work synergistically. In support to this initiative, TA will be provided (under intervention 2) to integrate drugs management information system with routine health management information system, for better forecasting of needs and quantification to assure a sustained supply and availability of drugs at facility level.

3.2. Strengthen the regulatory and quality assurance systems: a Federal Board for Pharmaceutical and Poisons (FBPP) established recently as an semiautonomous organization is in its infancy. This brings under its umbrella, system for the registration and de-registration of pharmaceuticals, National Drugs Quality Control Laboratory, Herbal and Traditional Medicines, inspection of medicinal products for their quality and safety in the market, licensing and inspection for Good Manufacturing Practices (GMP). These functions are vital to assure safety, quality, and efficacy of medicinal items, including for the three diseases; and this proposal will support FBPP in the following:

3.2.1 Building the organization and management capacity of FBPP to act independently and enforce its regulatory functions is mainstay in assuring quality through good practices in manufacture, storage and distribution, as otherwise the human lives will be at risk and the credibility of health systems undermines.

Therefore, in addition to providing TA to develop standard operating procedures (SOPs) and guidelines, e.g. for registration and de-registration of pharmaceuticals, inspection of medicine in the market as well as for GMP in their

18 Office of Technology Assessment, 1978, Assessing the efficacy and safety of medical technologies, Government Printing Press, USA, Washington DC 19 Rational use of medicines: progress in implementing WHO medicine strategies, a report of the secretariat to the Executive Board



production sites for their quality and safety, FBPP will be assisted by providing essential equipment, logistics and training of key officials for developing their knowledge and skills in enforcing regulatory functions (e.g. in registration, dossier assessment, and inspection of distribution channels).

3.2.2 Strengthen National Drugs Quality Control Laboratory (NDQCL), which is key in detecting counterfeit medicine, which in many cases is widespread account for 20-30% of samples collected from the market, will be an important input of this proposal. Rome Declaration20 calls for combating the counterfeit medicines. In Sudan, NDQCL plays an important role in quality control of drugs, manufactured locally and imported, and cosmetics etc. But, it is not pre-qualified by WHO as it does not fulfill criteria of Good Laboratory Practice (GLP), required for pre-qualification.

This proposal, in order to response to the call by Rome Declaration and to assure quality and safety of drugs, including for the three diseases, available on the market, will support the strengthening of NDQCL in order for pre-qualification by WHO. In this regard, WHO assisted in reviewing the existing capacity and a plan has been developed for its improvement. This includes, inter-alia, and this proposal will support the development of SOPs and guidelines and their implementation to ensure GLP, and for building the capacity of key staff by training them on specialized equipment and procedures.

3.3. Ensuring rational use: is important discipline, as conversely the irrational use of drugs (RUD) causes increased adverse drug reaction and drug events, and an increased incidence of antimicrobial resistance; and for TB, already there is a serious problem of multi-drugs resistance. Therefore, the World Health Assembly (2007) in its Resolution WHA60.16 calls member countries “to invest sufficiently in human resources and provide adequate financing in order to strengthen institutional capacity to ensure more appropriate use of medicines in both the public and private sectors "and" to consider establishing and/or strengthening…a full national programme and/or multidisciplinary national body, involving civil society and professional bodies, to monitor and promote the rational use of medicines".

In order to assure RUD, this proposal will support establishing programme for RUD as recommended by WHO. The Important elements of this programme include actions, focusing on public as well as private sector, like laying adequate emphasize of RUD in curriculum by introducing problem-based training in pharmacotherapy for pre-service training of medics, paramedics and nurses and developing Standard Treatment Guideline and facility specific formularies. System will be set up for establishing Drugs & Therapeutic Committees in hospitals, continuing medical education as a licensure requirement, independent drug information e.g. bulletins for public education.

3.4. Health technology assessment and management: with new health technologies being introduced, the health system’s capacity to effectively select, deploy, support, manage and utilize has been compromised. As a result, while it has contributed to increasing health care cost, impacting peoples’ equitable access to services. In addition, due to lack of efficient system for repair and maintenance, average operational life of equipment is far from being optimal.

Health technology assessment (HTA) and management, which has been argued as a tool to contain cost of health care21, aims to provide best evidence on health technologies for informing the policymakers on their safety, efficacy, effectiveness, ethics, impact on quality of life, and cost-effectiveness. Many countries have developed such systems, e.g. UK’s National Institute for Clinical Excellence, Canadian Coordinating Office for HTA etc.

3.4.1 Health Technology Assessment Unit will be set up in the Federal Ministry of Health to coordinate actions focusing on health technology. Through this proposal this unit will be assisted to: (i) undertake a comprehensive country situation analysis on health technology; (ii) formulate and adopt, through consensus of stakeholders, a National Health Technology Policy; (iii) develop a strategy and master plan for implementing Health Technology Policy; (iv) build capacity in SMOH for instituting HTA at the state level; and (v) introduce tools for health technology assessment, planning and management developed by WHO into everyday practice.

3.4.2 System for repair and maintenance of medical equipment: will be set up to assure not only timely repair, but also preventive maintenance in order to keep the equipment running. For this to achieve, this proposal will support the developing of a cadre of biomedical engineers in the ministries of health by providing training to the qualified personnel to mange health technology introduced into the health system.

It is planned that initially, a batch of twenty people - one from each of the 15 states and 5 more from FMOH- will undergo training in a foreign institute. In the next phase, those five trained for FMOH, with technical support through this proposal will develop a short skill building course at a local institute for training technicians operating different types of equipment in trouble shooting and preventive maintenance.



3.1.1: National essential drugs list and drug formularies updated for different levels of

3.1.2: framework agreed for Central Medical Stores and Donor funded

3.1.3: Integrated procurement, storage and supplies system



20 Declaration o Rome, 18 February, 2006, 'Combating Counterfeit Drugs: Building Effective International Collaboration' 21 WHO, 2008, Ensuring value for money in health care: the role of health technology assessment in the European Union



care including disease programs

procurement, storage and supplies system to operate synergistically

operationalised (orientation workshop for 3 staff from each locality for 2 days)



3.1.4: Integrated procurement, storage and supplies system evaluated

3.2.1.1: logistics and key equipment provided to FBPP to facilitate enforcing of its regulatory functions

3.2.1.2: guidelines/ SOPs updated for: registration & de-registration of medicine, dossier assessment, inspection of medicines in the market, and GMP inspection

3.2.1.3: short course established for pharmacists on the inspection of distribution channel and to identify counterfeit medicines

3.2.1.4: pharmacists (80) receive training on the inspection of distribution channels and to identify counterfeit medicines

3.2.1.4: pharmacists (80) receive training on the inspection of distribution channels and to identify counterfeit medicines

3.2.2.1: guidelines/ SOPs developed/ updated for good laboratory practice at National Drugs Quality Control Laboratory

3.2.2.2: Staff at National Drugs Quality Control Laboratory trained in using the updated guidelines/ SOPs

3.2.2:3 fellowships (6 man-months) granted to key lab staff to attend courses on GLP and use of specialized equipment



3.3.1: national policy and strategic plan developed for promotion of rational use of drugs

3.3.2: standard treatment guidelines developed/updated for different levels of care/facilities, including disease control programs

3.3.3: independent quarterly organ published to disseminate news/ views about rational use of drugs

3.3.3: independent quarterly organ published to disseminate news/ views about rational use of drugs

3..3.4: curricula for undergraduate medics, nurses paramedics, etc. include sessions on rational use of drugs

3..3.3: independent quarterly organ published to disseminate news/ views about rational use of drugs

3..3.5: a national program for the surveillance of adverse drugs reactions and to control antimicrobial resistance set up

3..3.3: independent quarterly organ published to disseminate news/ views about rational use of drugs

3.3.5: a national program for the surveillance of adverse drugs reactions and to control antimicrobial resistance operates

3.4.1.1: framework for health technology assessment agreed by all stakeholders

3.4.1.2: situation analysis done of the existing policies and practice on health technology assessment

3.4.1.3: a unit for health technology assessment is established

3.4.1.4: a national policy & strategic plan on health technology is developed

3.4.1.5: health managers (20) at state / institutional level orientated on health technology assessment

3.4.1.5: health managers (20) at state/ institutional level orientated on health technology assessment

3.4.1.5: health managers (20) at state/ institutional level orientated on health technology assessment

--- 3.4.2.1: fellowship (12 man-month)

3.4.2.1: fellowship (12 man-month)





granted for biomedical engineer training

3.4.2.2: A short skill building course (5 days) established to train technicians in preventive maintenance, minor repair and trouble shooting


3.4.2.3: workshops to train (80) lab and health technicians in preventive maintenance, minor repair and trouble shooting












Government


2008-12

4,601,000

Strengthening of localities in terms of improving storage conditions and to provide vehicles for transporting commodities to health facilities

Other: WHO 2008-09 127,000 Improve the safety and quality of medicine in the northern states

Other: UNFPA

2008-9 475,350

To support provision of safe reproductive health package

Other: UNICEF 2008-09 4,000,075 To improve access to health care by providing cold chain, medicine and other supplies






Scale up, quantitatively and qualitatively, the availability of HRH at different levels of health care that it matches the basic standards





Human resource



Background and relevance: human resources for health (HRH) denotes physicians, nurses, midwives, and pharmacists, as well as technicians and other paraprofessional personnel working for the public as well as private sector. These also include untrained and informal sector health workers, such as practitioners of traditional medicine, community health workers, and volunteers22. A broader picture of HRH in Sudan presented above, indicated the acute shortage of some categories, vital for health care delivery, mal-distribution between regions and the levels of care, and poor moral due to weak career structure and poor working conditions. This issue is since cross-cutting, Sudan’s march towards achieving health related MDGs, including MDG 6, which are heavily dependent on the availability and deployment of adequate and efficient health workforce, is slow and the country is far from its targets.

Therefore, NHP places HRH high on its agenda (s8.1.5), particularly in the context of rehabilitation and reconstruction of the war ravaged health system that has also suffered from years of internal and external brain drain. This directive is translated in the 5-year Strategic Plan for Health Sector as SO 6, which calls for adequate production, equitable distribution and retention of skilled human health personnel based on the health system needs. While reforms are needed in the pre-service and in-service training for all HRH categories, government adopted a Sudan Declaration for Promotion of Nursing and Allied Health Workers' Educational Reform to upgrade the nursing and allied health professional cadres to post-secondary diplomas and bachelor programs for new entrants and bridging programs for existing workforce. Academies of Health Sciences (AHS) – one in each state – are the mainstay of this program.

The TWG for GF/HSS discussed issues surrounding HRH in successive meetings and DGHS in their meeting defined objective for this service delivery area (HRH) and outlined activities to be carried out over next five years. Many of these compliment those identified in GAVI/HSS and MDTF supported DHSD project; and are explained as below:

4. Objective: of this intervention is to scale up, quantitatively and qualitatively, the HRH to match the basic standards of their availability at different levels of health care. In order to achieve this objective, a variety of activities, which cover all aspects of HRH, i.e. planning, management and training, are planned. While some interventions, e.g. developing a human resource plan and strengthening HRH observatory is supported through a grant from Global Health Workforce Alliance (GHWA), the following activities are included in this proposal:

4.1. Update pre-service curricula and training methodologies: employed for categories like, medical, nurses paramedical and allied have not been updated; thus affecting the capacity of health workforce in meeting the new challenges. While new areas, like counseling etc. may be included in curricula, it should also emphasize on the social and political economy (poverty and political instability) as determinants of disease. These are important, particularly in the context of the three diseases. In addition, education institutes continue to use old disciplinary and body systems’ models that use hypothetical-deductive reasoning, typical of backward reasoning.

This proposal seeks to review the existing curricula and the training methodologies being employed for the different categories of health workforce, including health managers. New models that use inductive reasoning approaches will be explored, since they allow forward clinical reasoning on a problem-based format. One such model is clinical presentation curriculum which ensures that principles of evidence-based medicine are incorporated into clinical teaching and that the training material so developed can be modified for use along the medical continuum, i.e. residents, fellows and practitioners. In this regards, lessons will be learnt from the experience of other countries, and measures will be taken for developing/ adapting these models on pilot basis in a selected university.

4.2. Scaling up health workforce: the AHSs have set up courses, as required under Sudan Declaration, for nurses

22 WHO (2006) Working together for Health, World Health Report



and medical assistants. There is a need to set up courses, both diploma/BSc. and bridging, for midwifes, health visitors, technicians and allied. In this regards, training of tutors is required, both for the new entrants and to build the capacity of those currently working as core faculty as well as associate faculty.

The AHSs have been set up in the hitherto nursing and medical assistant schools. These are dilapidated and lack essential equipment, transport and essential furniture. With support from WHO, four AHSs were partially rehabilitated, while it is planned to rehabilitate other four through MDTF/DHSD project and one by GAVI/HSS. This proposal, therefore, seeks to fill in the gaps left in the rehabilitation done, and the three Darfur state academies of health sciences. Also, these academies will be provided vehicles for the commuting nurses, midwifes, and health visitors to their training sites and equipment, including the provision of skill labs, IT and audio-visual gadgets.

4.3. Instituting community and home based care: advocated by UNICEF (Accelerated Child Survival and Development Initiative) and WHO to tackle HRH shortages, this approach is likely to specifically work in the context of Sudan (see also intervention-1) to improve access by people to health services, including for the three disease. Through GF/Round 7 funds are available to develop home-based care for Malaria. Building on the same, and to improve access to health services by the dwellers of rural and hard to reach areas and nomads, community and home based services will be instituted.

This proposal will support developing a cadre of community health volunteers (CHVs) who will be supported by community health workers (CHWs), working from the health facilities in two pilot states (North Kodofan and Red Sea). CHW schools in these states will be strengthened and training material developed for the training of CHVs. The For this, lessons will be learnt from the experience of Iran’s women health volunteers and Pakistan’s lady health workers’ programme. NB: see also intervention for health services delivery.

4.4. Enhancing HR retention: require definition and implementation of a robust agenda, including career and incentive structure for health staff including those working in programmes and private sector. This is important, as otherwise there will continue to be a brain drain, internally and externally; and as a result, there occurs skill imbalance and inequitable distribution of HRH with periphery, i.e. states and localities, suffering the most. Thus, the dream of providing universal health care coverage, including for the three diseases, continues to become more distant.

To address this issue, therefore some structural intervention rather than an ad-hoc solution like topping up of salary is required. Complementing GAVI/HSS operational research for testing feasibility of different interventions and to come out with a systematic approach aimed at enhancing staff retention at the sate and locality level, this proposal will support the provision of input for interventions23. Furthermore, research on issues like gender and immigration of health workforce will be conducted.

4.5. HRH policies, strategies and plans in the ministries of health require updating, learning from the evidence and experience of other countries of the region. This is important since issues in HRH are cross-cutting that impact the outcome of any health intervention, including for the three diseases. But, Directorates of Human Resource at federal and state level, which are responsible for developing and implementing policies and strategies, need building their capacity. Through a modest grant from Global Health Workforce Alliance (GHWA), it is planned to strengthen HRH Observatory and setting up a short course on HRD.

Through this proposal, it is proposed to assist Federal Directorate of Human Resource to update and develop an evidence based policy on different categories of human resource, including for the three diseases. In order the HRH policies and strategies are implemented, the State Directorate of Human Resource will be strengthened by providing them essential office equipment. This input will enable the HR Directorates in the state to better manage HR.



4.1.1: curricula and training methodologies for medics, nurses and paramedics reviewed vis-à-vis developments in the field

4.1.2: framework developed for updating curricula and training methodologies for undergraduate education

4.1.3: curricula and training methodology for

4.1.4: updated curricula and training methodologies piloted in one university

4.1.4: pilot phase continues

4.1.4: pilot phase continues

4.1.5: initial evaluation of updated curricula and training methodology conducted to improve design

23 The package under the staff retention scheme may include, either solitary or in combination: (i) Provision of a house to live while in service or house rent; (ii) Support to the

incumbent that the spouse, in case s/he is in public service, joins the same station; (iii) Provision of teaching allowance if the staff is instructor; (iv) Provision of hardship allowance in

case of 3 Darfur states; (v) Fair and equal chances of training and skill building including from GAVI/HSS support; (vi) Payment of tuition fee to the children studying in local school

(where the parent is posted) up to secondary school level.



undergraduate education updated, and a detailed plan for implementation developed

4.2.1: investment plan developed for rehabilitation and refurbishment of Academies of Health Sciences and CHW schools

4.2.2: 4 State Academies of Health Sciences rehabilitated

4.2.3: 4 State Academies of Health Sciences refurbished and equipped with skill labs, IT, teaching aids

4.2.4: transport (4 minibuses) provided for commuting students

4.2.5: fellowship (12 man-months) granted to CPD programs (White Nile and Gadarif)

4.2.2: 4 more State Academies of Health Sciences rehabilitated

4.2.3: 4 more State Academies of Health Sciences refurbished and equipped with skill labs, IT, teaching aids

4.2.4: transport (4 minibuses) provided for commuting students

4.2.5: fellowship (12 man-months) granted to CPD programs (Gezira and Khartoum)

4.2.6: integrated on-job bridging courses provided (114 localities * 15 PHC workers = 1710)



--

4.3.1: CHW schools in 2 pilot states (North Kordofan and Red Sea) rehabilitated, refurbished and equipped

4.3.2: training material developed for training of community health volunteers

4.3.3: community health volunteers trained ( batch of 50 twice a year * 2 states =200)



4.4.1: research designed on gender and migration in Human Resource for Health; and incentive package for HR retention defined from GAVI/ HSS intervention

4.4.2: incentive package provided as part of operational research for enhancing HR retention

4.4.3: research undertaken on gender and migration in HRH

4.4.2: incentive package for enhancing HR retention – continues

4.4.3: research on gender and migration in HRH - continues

4.4.4: research results are available and disseminated

4.4.5: evidence based sustainable HRH policy and strategic plan developed

4.5.1: HRH policies for different categories of health workforce updated

4.5.2: Directorates of HR at Federal and 15 States provided key office equipment / furniture

-- -- --










Government

2008 1,500,000

Academies of Health Sciences in center and states mainly for salary and recurrent expenses


2008-12 1,384,300

Support MSc. level training in Medical Entomology and Vector Control

Short courses for malaria teams in IVM, epidemic, community mobilization and PSM

Other: WHO 2008-09 830,620

Support for the restructuring of the HRH directorates at Federal and 15 Northern State

Other: UNICEF

2008 6,092,334

Human resources for planning, implementation and evaluation of health and nutrition projects strengthened

Other: GAVI HSS 2008-12 1,952,000 Develop human resources systems and policies

Invest in training institutions for PHC workers by supporting Academies of Health Sciences in 4 states

Institutionalize Continuing Professional Development programmes as a pilot in four AHSs

Other: MDTF/DHSD 2008-2011 3,633,000 Develop national and states strategies for HRH; rationalize and investment in training schools and equipment (physical renovation and equipment.

Other: JICA 2,000,000 Training of Midwives and Community Health Promoters, and rehabilitation of 2 midwifery school






Strengthen health financing function of the health system assuring equity and access to health service





Health financing



Background and relevance: while health sector in Sudan is generally under funded, public sector health spending is skewed towards hospital care. The primary and first-referral care, particularly in the poorer states, suffers from this under-financing and inequitable allocation of resources24. The ultimate brunt of such a situation is born by the household that has to pay out of pocket (it exceeds 60% in Sudan), and in many cases triggers the catastrophe and impoverishment. People suffering form the three diseases are no exception, and face the financial barriers to accessing health services, perpetuating the cycle of disease and poverty.

The NHP (s8.1.3) and 5-year Strategic Plan for Health Sector (Strategic Objective 6), therefore aim at addressing the financial barriers to accessing health services and to promote fair financing in health. Within the remits of this aim, the TWG and State DGHSs defined the following objective that was later endorsed by the CCM.

5. Objective: Strengthen health financing function in health system, assuring the equity and access to health service, particularly for the poor and vulnerable; and most of those who suffer from the three diseases fall in this category.

In order to achieve this objective, the TWG and State DGHSs identified, through successive deliberations, a number of initiatives: greater investment in health by government and expansion of social health insurance; and to compliment these efforts by introducing community health insurance schemes, essentially building on Sudan’s experience of community based initiatives (CBIs). These are explained below:

5.1: Greater investment in health by the government is often considered as the remedy, but question arises, what is the evidence of under-funding, and how to rectify such a situation. That is, there is a need to create evidence, e.g. by establishing national health accounts (NHAs), and using this evidence suggesting an approach for equitable allocation of resources. The former will help in mapping resources, both public and private, to assist policy-makers in making informed decisions about financing of health services, including for the three diseases. The latter, which will draw on the former, will serve as a tool for policy makers to consider equity in allocation of resources, thus alleviating barriers to accessing health services, particularly for poor and vulnerable. These two activities are explained below:

5.1.1: National health accounts: this tool assists in mapping the flow of funds in health sector; and based on such evidence, government can be encouraged to develop policies for sustainable health financing, including for the three diseases. But, for a greater benefit, this exercise should be conducted regularly, because a time series provides temporal context in which policy analysts can not only look at a given year’s figures, but also provides trend patterns over years in financing and consumption against which to assess the progress towards meeting health system goals.

First NHA for the fifteen northern states will be carried out in 2009 with support from GAVI/HSS and Multi-Donor Trust Fund (MDTF) supported Decentralized Health System Development (DHSD) Project. This proposal, building on the input by GAVI/HSS and MDTF/DHSD project, will support activities associated with another round of NHA in 2011, to essentially include sub-national health accounts for the three diseases: Tuberculosis, Malaria, and HIV/AIDS. Thus, providing evidence as an argument for a greater contribution by the government to these programmes.

5.1.2: Devise an approach for equitable allocation of resources: it is often said that health sector is under-funded. But, It is also argued that the long civil war in the South and now in Darfur has been due to the inequitable distribution of resources, be they financial or human. This inequity prevails all over in Sudan, geographically – some states being more developed than the others, between sectors, and within sectors between programs and levels of health care, including for the three diseases. Hospital and big institutions get major chunk, leaving little for PHC and rural areas.

This proposal envisages developing an approach for the equitable allocation of resources. TA will be provided for

24 WHO, 2007



tracking public and private health financing schemes for the levels of allocations per capita by state and geographic region and by types of services. Then, a formula, acceptable to stakeholders, will be developed that will ensure that the national resources - both financial and human – which are earmarked for health, are more equitably distributed amongst programs and institutions as well as across the states for the benefit of all including for the three diseases.

5.3. Social health insurance: For good performance of health system, there is a need, inter-alia for effective risk pooling, as evidence mounts that where there is no such mechanism, poor have to meet the cost of health care from out of pocket payments, driving them further into poverty25,26. The National Health Insurance Fund in Sudan covers over quarter of population, mainly government employees, with varying degree of coverage in different states. The informal sector, which accounts for the majority of poor and vulnerable, is largely uncovered. Particularly, these are the displaced people due to the long civil war in the south and Darfur, who are also prone to the three diseases.

Under MDTF/DHSD project, TA is planned to undertake in 2009 an in-depth study of the national and a case study of state level health insurance programs. Complementing this initiative, this proposal will invest in the actuarial and cost effectiveness analysis studies and management development required to expand the social health insurance to ensure equitable access to health care for the population, particularly the poor and vulnerable.

5.4. Community health insurance schemes: in Sudan quite frequently, droughts and floods cause humanitarian emergencies and ecological factors expose the population to infectious and parasitic diseases, including malaria and a host of neglected tropical disease. But given that it is a large country with vast distances and poor roads and transport structure, rural dwellers including nomads, who constitute almost 60% of its population, have little access to health care, and any attempt at that is marred by geographical as well as the financial barriers.

Sudan, supported by WHO, has experimented Community Based Initiatives (CBIs), especially the Basic Development Needs (BDN) as a strategy to tackle poor health in disadvantaged communities. The CBI approach emphasizes community participation in priority setting, planning, implementation, management, monitoring and evaluation; thus ensuring the sustainability and ownership of interventions by the communities. Building on this experience, National Health Insurance Fund, working with partners, e.g. local schools, and WHO leading the exercise, communities will be organized to develop health insurance schemes. It is planned, after preparatory phase in year-1, communities will be developed and entered through income generating CBIs, one each year in one locality in 15 northern states, making a total of about (4 yr * 1 locality per year * 15 states) 60 schemes over the grant period. The CBIs will then form a launching pad to work with organized communities for piloting the community health insurance schemes. In this arrangement, the income generated through CBIs will be used to pay the premium for the poor and destitute.

5.5. Capacity building: is another activity that will focus on the organizational development of Health Economics Unit (HEU) in FMOH and enhancing understanding of health managers in state and localities about health system. That it function was not only to protect and promote health, but also to protect people from getting poor due to ill health. This is important, as Sudan is a decentralized federal state with authority devolved to the provinces/states, albeit in theory essentially due to the latter lacking adequate capacity, particularly in health financing.

Under GAVI/HSS support, a modest quantity of equipment and training of key staff of HEU at master/diploma level, is planned. But, there is no such capacity at the state and locality level. Therefore, to compliment this input, through this proposal focal persons in the state health planning directorate will be identified and trained in health economics to build a critical mass. Further, a short training course of 2-3 weeks on health economics/ financing will be organized at a local institute to develop the capacity of health mangers at state and locality level as an ongoing program.



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5.1.1.1: health system boundaries defined for financing health services including HIV/AIDS, Malaria and Tuberculosis

5.1.1.2: survey on household health services utilization and expenditure and variables for HIV/AIDS, Malaria and Tuberculosis, is conducted

5.1.1.3: data collected from financing agents at

5.1.1.4: first NHA including sub-national health accounts for the three diseases constructed

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25 Supon Limwattananon, Viroj Tangcharoensathien and Phusit Prakongsai: Catastrophic and poverty impacts of health payments: results from national household survey in Thailand, Bulletin of the World Health Organization, August 2007, 85 (8) 600-614 26 Ke Xu, David B. Evans, Guido Carrin, Ana Mylena Aguilar-Rivera, Philip Musgrove, and Timothy Evans: “Moving away from out-of-pocket health care payments to prepayment mechanisms is the key to reducing financial catastrophe”. Health Affairs 26, no. 4 (2007): 972–983



different levels of health care, including for HIV/AIDS, Malaria and Tuberculosis

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5.1.2.1: framework agreed for an equitable distribution of national resources between sectors and regions and programs within health sectors

5.1.2.2: Public and private health financing schemes tracked for the levels of allocations per capita by state and geographic regions and by types of services

5.1.2.3: formula devised to equitably distribute financial /human resources between sectors, regions, and within health sector amongst programs

5.1.2.4:Mechanism (e.g. Intersectoral Steering Committee) available to develop a sustainable health financing policy

5.1.2.5:Advocacy for getting research into policy and practice

5.1.2.4:Mechanism (e.g. Intersectoral Steering Committee) available to develop a sustainable health financing policy

5.1.2.5:Advocacy for getting research into policy and practice

5.1.2.6:Increased and equitable allocation of financial and human resources between sectors, regions, and within health sector amongst programs

5.3.1: Alternate resource generation mechanisms reviewed and one for Sudan is suggested

5.3.2: Alternate payment mechanisms reviewed and one for Sudan is suggested

5.3.3: actuarial and cost effectiveness analysis studies done to determine the feasibility of expanding social health insurance

5.3.5: fellowships (24 man-months) granted for key insurance staff at federal and state levels

5.3.4: framework and detailed plan agreed for the expansion of social insurance to cover the informal sector


5.3.6: household survey designed and conducted to classify population (number, size of family, income, gender, age, risks etc) and distribute cards


5.3.7: more families: informal sector, including IDPs come under cover


5.3.7: more families: informal sector, including IDPs come under cover

5.4.1: a framework, learning from BDN approach, developed for community health insurance scheme

5.4.2: communities (60) selected for developing community based initiatives (CBI) and health insurance scheme

5.4.3: detailed protocol and master plan developed for implementing the scheme

5.4.4: household survey designed and conducted in 20 communities to classify population (no, size of family, income, gender, age, risks etc)

5.4.4: household survey conducted in 20 communities

5.4.5: communities (20) developed by holding 2 meetings with each

5.4.6: communities (20) developed are funded partially for implementing small income generation community based initiatives

5.4.4: household survey conducted in 20 communities


5.4.6: communities (20) developed partially funded for implementing small income generation community based initiatives


5.4.6: communities (20) developed partially funded for implementing small income generation community based initiatives

5.4.7: community health insurance scheme developed



5.4.7: community health insurance scheme developed and implemented

5.4.7: community health insurance scheme developed and implemented

and implemented

5.4.8: scheme evaluated for its efficiency in reaching out poor

5.5.1: a short course designed for training health managers on health financing /economics

5.5.2: two rounds of short course delivered for (40) health managers from states and localities

5.5.3: fellowships (24 man-months) granted to candidates from states



5.5.4: state directorates of health planning conduct economic evaluation and develop annual health plans














Government

Other Global Fund Grants (with HSS elements

Other: GAVI HSS 2008-2012 696,210 Improve capacities and knowledgebase for equitable and sustainable health financing by: (i) Conduct NHA in 11 states; (ii) developing/adapting pro-poor and sustainable health financing policy; and (iii) conduct household expenditure and health services utilization research in 11 northern states

Other: MDTF/DHSD 2007-11 374,600

To develop NHA in 4 states



4B.2 Engagement of HSS Key Stakeholders in Proposal Development

(a) Briefly describe which and how important HSS stakeholders (e.g., ministries of planning, finance etc) have been involved in the identification and development of appropriate HSS cross-cutting interventions for this Round 8 proposal, and how coordination of the proposed HSS cross-cutting interventions has been ensured across the three diseases (and, where relevant, beyond).

The development of this proposal was comprehensive and inclusive of stakeholders at all stages. It started with briefings for the drafting committee on programmes for the three diseases. It was followed by a series of meetings and workshops. A fuller detail of the application development process is at Sudan-Attachment 1. In brief, it involved an extensive exercise with the following:

1. Briefings and discussion of the drafting committee with national programmes for the three diseases

2. Technical Working Group

3. State Director General of Health Services

4. State Directors of Health Planning and Development

5. Brain storming sessions with key staff from health service delivery area

In this manner, while TWG brings together stakeholders from the three diseases at national as well as state and the programme and institutions’ level, involvement of state DGHS and Planning Directors was important. They will lead the implementation of proposal and by being involved at conceptualization and development stage will ensure their ownership to the interventions. Likewise involvement of the key staff from different service delivery areas ensured not only the technical soundness of the proposed contents, but also their ownership during implementation. The implementation matrix (Sudan-Attachment 2) outlines the relationship between goals, objectives, activities and milestones as salient inputs, it also indicates inputs from other sources/ partners complementing this proposal. NB: if WHO assumes the role of Sub-Recipient, it will work through these identified agencies.

In addition, the drafting committee under the leadership of the Assistant Undersecretary, Health Policy, Planning and Research held meetings with officials from the following:

1. National Health Insurance Fund

2. Khartoum State Ministry of Social Welfare

3. Khartoum Health Insurance Corporation

4. Ministry of Finance and Economic Affairs

5. Intersectoral Collaboration Committee

Whereas first three organizations will be partners in implementing intervention about health financing, involvement of the Ministry of Finance and Economic Affairs is a key in ensuring enhanced government funding and sustainability of interventions being proposed. Also, given that health is a multi-faceted issue; and particularly the three diseases, the engagement of Intersectoral Collaboration Committee in the developing of this proposal is a step forward for ensuring multi-sectoral action. In this manner, the proposal is likely to address social determinants of health and broadening the stakeholders’ base for the health sector.

The CCM was fully involved in the application development process. In its meeting 01/2008, held on 13/1/2008 it appointed a committee to steer the proposal for health systems strengthening. Later, in its meeting on 26 May, 2008, it endorsed the aim, objectives and major interventions proposed for the application. The first draft proposal was shared by email with CCM members on 18-06-08. Comments received were incorporated and second draft was circulated by email on 23-06-08 in preparation to its meeting on 25-06-08. The comments by the participants of meeting, particularly by UNICEF and WHO were useful and have since been incorporated into this proposal. The CCM in its meeting on 25-06-08 endorsed this application for GF/R8 (Sudan-Attachment 3).

Furthermore, drafts of the proposal at different stages of development were shared with stakeholders by email. The comments were also received during informal meetings and discussions. Feedback received was considered by the drafting committee and incorporated into the proposal.

(b) Has the CCM (or Sub-CCM) ensured that:

(i) the HSS cross-cutting interventions in this proposal do not repeat any request for funding under any of the specific disease components (section 4.6 of each disease)?; and

Yes r



(ii) the detailed work plan** and the 'Performance Framework'** (Attachment A) for this disease includes separate worksheets which clearly identify the HSS cross-cutting interventions by objective, SDA, and activity for the initial two years of the proposal?

** Applicants may prepare a separate work plan (Attachment) for the HSS cross-cutting interventions and a separate 'Performance Framework' (Attachment A) if they prefer.

The following attachments added to the application:

Attachment 2 - Health system strengthening: implementation matrix

Attachment A - Health system strengthening: performance framework

Yes

4B.3 Strategy to mitigate initial unintended consequences

If there are some perceived initial disruptive consequences of the planned investment in any or all of the HSS cross-cutting interventions set out in section 4B.1 above (e.g., human resource movement or loss for other services):

What were the factors considered when deciding to proceed with the request for the financial support in any event?

What is the country's proposed strategy for mitigating these potential disruptive consequences?

This proposal, however technically sound and feasible, runs certain risks, which unless addressed timely and robust mitigation strategies are adopted, there is a danger of impediment to implementation, jeopardizing the sustainability of interventions and the desired outcomes are not achieved. Therefore, a risk analysis was conducted and mitigation strategies discussed. It appears that many risks would be, and would have been averted if the health system was strong. While this proposal aims to work towards that goal, following mitigation strategies are considered:

Risks Mitigation strategies

1. Sudan is prone to emergencies and disasters which often cause diversion of resources, financial, material and human, thus risking the development efforts.

1. The MoH has been working with humanitarian agencies for developing capacity at state level, including building buffer stocks and contingency plan to meet the challenges; thus avoiding any shift of resources in the event of emergency.

2. While CPA has eased the situation in South, conflict continues in Darfur, and there is a small scale problem in South Kordofan and Abyei.

2. CPA brought dividend as peace and social sector development, sanity seems to prevail. While brokering and maintaining peace is political, health development can be catalytic and an entry point.

3. There has been and the trend is likely to continue for urbanization and consequent shifting of resources to the capital and big cities, leaving rural areas unattended.

3. Through health interventions in peripheral rural areas, and this application proposes doing that, trend can be decelerated. The government, as indicated in its Mid-Term Expenditure Plan, is also increasingly investing in health and given the soaring oil revenue, this trend is likely to continue.

4. This proposal requires availability of skills both from inside and outside the country. However, given the sanctions and continuing brain drain there is a likelihood of the shortage of core competencies.

4. This application proposes short and long term training of staff that will contribute to building a critical mass. In addition, the beneficiary fellows in return will commit to work for a specified period. WHO, which will be asked to act as sub-recipient, will be used to channel consultants.

5. In a country, which harbors a host of communicable diseases, medical approach to health dominates, it is often hard to advocate the case of health system strengthening - a relatively new concept in Sudan.

5. This proposal, as indicated above (s-4B2(a), has been developed in partnership with stakeholders, including those who will lead implementation. This process, which was intensive, helped in broadening the understanding of stakeholders about health system and the importance of investing in it.

r


CP_CCM_R8_SUD_THSS_PF_23Sep08_En 90

5B. FUNDING REQUEST – HSS CROSS-CUTTING INTERVENTIONS

5B.1 Detailed Budget Steps in budget completion: 1. Submit a detailed budget of the HSS cross-cutting interventions in Microsoft Excel format

using the same numbering for budget line items as in the description of HSS cross-cutting interventions in section 4B.1.

The detailed budget must be submitted as a clearly numbered annex.

The HSS cross-cutting interventions may be prepared as a separate Excel worksheet of the disease budget, or a separate file (Excel workbook) at the applicant's election.

For guidance on the level of detail required (or to use a template if there is no existing

in-country detailed budgeting framework) refer to the detailed budget guidance in section 5.1 of the Round 8 Guidelines. (i.e., same instructions as for the disease budget preparation)

2. From that detailed budget, prepare a 'Summary by Objective and Service Delivery Area'

(section 5B.2). (Note – 'SDAs' for the purpose of HSS cross-cutting interventions are not the same as the SDAs for the diseases. Refer to s.5B.2 of the Round 8 Guidelines for more information).

3. From the same detailed budget, prepare a 'Summary by Cost Category' (section 5B.3); and 4. Ensure the detailed budget is consistent with the detailed workplan for HSS cross-cutting

interventions, and the 'Performance Framework' for HSS cross-cutting interventions (Attachment A).

READ THE ROUND 8 GUIDELINES FOR MORE INFORMATION

Applying for funding for HSS cross-cutting interventions is optional in Round 8

SECTION 5B CAN ONLY BE INCLUDED IN ONE DISEASE IN ROUND 8 and only if this disease includes the applicant's programmatic description of HSS cross-cutting interventions in s.4B.

Read the Round 8 Guidelines to consider including HSS cross-cutting interventions



5B.2 Summary of detailed budget for HSS cross-cutting interventions by objective and service delivery area

Table 5B.2 – Summary of detailed budget by objective and service delivery area

Budget breakdown by SDA

Objective Number

Service delivery area (Use the same numbering as the detailed

work plan for HSS cross-cutting interventions)


1 Service delivery 336,727 3,624,467 3,721,905 3,721,905 3,255,393 14,660,397

2 Information 227,053 895,523 666,488 615,503 353,156 2,757,723

3 Medical products and other health technologies 240,196 412,072 334,972 330,327 325,568 1,643,134

4 Human resource 172,329 2,168,357 4,162,359 2,500,701 2,525,627 11,529,372

5 Health financing 134,940 1,051,197 1,837,613 669,263 652,042 4,345,055

Use "Add Extra Row Below" from "Table" menu in Microsoft Word menu bar to add as many additional rows as required to ensure consistent with the 'Performance Framework'

Total funds requested from Global Fund for HSS cross-cutting interventions (i.e., total for all the interventions described on a programmatic basis in s.4B.1, where included in Round 8)

1,111,245 8,151,616 10,723,336 7,837,698 7,111,785 34,935,679



5B.3 Summary of detailed budget by cost category

Summary information provided in the table below should be supplemented with additional detail in section 5B.4 below.

Table 5B.3 – Summary of detailed budget by cost category

Breakdown by cost category (same currency as selected by Applicant on face sheet of the Proposal Form) Avoid using the "other" category unless necessary – read the Round 8 Guidelines.


Human resources 0 18,000 136,000 136,000 136,000 426,000

Technical and Management Assistance 674,400 1,194,220 274,450 200,550 363,150 2,706,770

Training 113,400 665,000 2,672,100 2,707,600 2,539,300 8,697,400

Health products and health equipment 0 0 10,000 10,000 10,000 30,000

Pharmaceutical products (medicines) 0 0 0 0 0 0

Procurement and supply management costs 0 0 0 0 0 0

Infrastructure and other equipment 193,000 4,147,500 3,819,500 2,864,500 2,630,500 13,655,000

Communication Materials 0 5,000 35,000 65,000 45,000 150,000

Monitoring & Evaluation 29,424 215,841 283,937 207,530 188,309 925,040

Living Support to Clients/Target Populations

0 0 0 0 0 0

Planning and administration 101,021 741,055 974,849 712,518 646,526 3,175,969

Overheads 0 0 0 0 0 0

Other: (To be further defined to meet national budget planning categories)

0 1,165,000 2,517,500 934,000 553,000 5,169,500

Total funds requested from Global Fund for HSS cross-cutting interventions (s.4B.1)

1,111,245 8,151,616 10,723,336 7,837,698 7,111,785 34,935,679


5B.4.1 Briefly explain any significant variations in cost categories by year, or significant five year totals for those categories.

HALF PAGE MAXIMUM The cost categories assigned to different activities are unlikely to change. A possible exception could be the ‘planning and administration cost’ which is calculated on the assumption that WHO will be the Sub-Recipient and will charge programme support cost. Financial quantities for activities that spill over and or repeat over next years are kept same in the budget sheet. However, these quantities are likely to change over next years; and while costing such activities, factors like prevalent inflation, applicable taxes and duties will be considered.

5B.4.2 Human resources

In cases where 'human resources' represents an important share of the budget, summarize: (i) how these amounts have been budgeted in respect of the first two years; and (ii) to what extent human resources spending will strengthen health systems’ capacity at the client/target population level. (Useful information to support the assumptions to be set out in the detailed budget includes: a list of the proposed positions that is consistent with assumptions on hours, salary etc included in the detailed budget; and the proportion (in percentage terms) of time that will be allocated to the work under this proposal.

Attach such information as a numbered annex to the proposal, and indicate the annex number in the checklist at the end of this section.)

HALF PAGE MAXIMUM

Human resources cost category is just more than 1% of the total financial outlay of the HSS cross-cutting interventions; and only US$ 18,000 is budgeted for year 2. The cost for human resource is based on the currently prevalent rate in Sudan for the type of personnel required. However, it might change subject to the availability and the qualification of the incumbent. Moreover, if WHO is the Sub-recipient, then rates of WHO will be applicable. The type of human resource asked for in the proposal is meant to assist in implementing the intervention, as well as to add to the capacity in the ministry in two ways. Firstly, it will be by bringing in better skills and knowledge and transferring this to the people they will be working with in the ministry. Second, since they would be WHO staff (if WHO is Sub-recipient) they will themselves benefit by knowing the organization and its procedures.

5B.4.3. Other large expenditure items

If other ‘cost categories’ represent important amounts in the summary in table 5.4, (i) explain the basis for the budget calculation of those amounts. Also explain how this contribution is important to implementation of the national disease program.

Attach supporting information as clearly named and numbered annex.

HALF PAGE MAXIMUM

The basis for financial quantities is given in the budget sheet and will not be repeated here. However, the cost categories that take up the major allocation are explained as below:

Out of the service delivery areas (SDA) ‘services delivery’ will receive maximum input of over US$14 million. The activities that will be carried out under this service delivery area (SDA) will enable health system to deliver health services. That is, this input will improve the access by the people of Sudan to equitable health services including for the three diseases and other programs. The ‘health workforce’ with an estimated allocation of over US$11 million is the second highest recipient of the grant. While this SDA is important in the context of Sudan, any input in health workforce per se will lead to efficient usage of fund allocated to the aforementioned SDA.

Considering the cost categories, ‘infrastructure and other equipment’ is the top recipient with an allocation of over US$13 million, followed by ‘training’ (over US$8 million) and ‘others’ (over US$5 million). In the context of Sudan this is understandable given that the country has come out of a major


and protracted conflict that lasted for two decades. As a result, the infrastructure, including essential equipment and furniture is dilapidated, turning many health care delivery outlets non-functional or at the best not offering quality services, including for the three diseases. Such a situation extends to the training institutions as well, which as a result do not function effectively.

The second top cost category is ‘training’, which is important given that there has been brain drain both internally as well as externally, depleting the health system in Sudan of the trained health workforce at all levels of care. Geographically, the periphery and rural areas where 65% of the population lives suffers the most. Therefore, this proposal invests in ‘training’, pre-service as well as in-service of the health workforce to effectively deliver health services, including for the three diseases.

‘Other’ is another cost category with an allocation of over US$5 million. This brings together items like, printed supplies, research studies, including piloting of interventions, and surveys, e.g. for health accounts; and was categorized so since such types of expenditure could not be posted under any other defined cost category. These are important activities which generate evidence for developing sustainable policies, be they for the human resource or financial and health technology including medicine and their rational use.

Sudan Tuberculosis

1

2345

value Year Source Year 1 Year 2 Year 3 Year 4 Year 568 2006 Specify-

Reports, Surveys, (WHO Global TB Report)

66 64 62 59 56

419 2006 Specify- Reports, Surveys, (WHO Global TB Report, TB Disease Prevalence Survey)

406 394 382 363 345

36% 2007 R&R TB system, quarterly reports

40% 45% 50% 60% 70%

82% 2006 R&R TB system, quarterly reports

84% 85% 87% 87% 87%

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Objective Number

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

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Case detection rate: new smear positive TB cases

outcome Treatment success rate: new smear positive TB cases

please select… Please Select…

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Program Objectives, Service Delivery Areas and Indicators

please select…

Although GF R5 target is to achieve TSR of 86% by Y4 of R5 (i.e. 2009) and maintain it to Y5 of R5 (i.e. 2010), because of the reasons mentioned in the proposal (i.e. access in war-affected areas, quality of DOTS etc) TSR has not been increased to that level. Actually it is 82% in 2007. We therefore modified the target in a realistic way by aiming to achieve 70% by Year 2 of R8 (i.e. 2010).

TB mortality rate (all forms of TB)

Impact and outcome Indicators Indicator

TB prevalence rate (all forms of TB)impact

Baseline

outcome

Targets Comments*

3% reduction from Y1to Y3 of R8 and 5% reduction from Y4 to Y5 of R8 (see the "Indicator calculation" worksheet.

Objective description

Prevent and control MDR-TB, and address TB contact management

Please Select…


please select…

Expand DOTS, especially in war-affected areas in the Western region (Darfur States)

Program Goal, impact and ouctome indicators

Attachment A - Tuberculosis Performance Framework

Program DetailsCountry:Disease:Proposal ID:

* please specify source of measurement for indicator in case different to baseline source

GoalsTo drastically reduce the TB burden in Sudan, particularly among poor and vulnerable populations in line with the 2015 MDG and the Stop TB Partnership targets.

impact Although GF R5 target is to reduce mortality to 40 per 100,000 by Y4 of R5 (i.e. 2009) and 35 by Y5 of R5 (i.e. 2010), because of the reasons mentioned in the proposal (i.e. access war-affected areas, quality of DOTS etc) the mortality has not been reduced to that level. According to the WHO Global TB Report, it is still 68 in 2006. We therefore modified the target in a realistic way by applying 3% reduction from Y1to Y3 of R8 and 5% reduction froY4 to Y5 of R8 (see the "Indicator calculation" worksheet).

Pursue high qualtiy DOTS

Comments

Although GF R5 target is to achieve CDR of 75% by Y4 of R5 (i.e. 2009) and maintain it to Y5 of R5 (i.e. 2010), because of the reasons mentioned in the proposal (i.e. access in war-affected areas, quality of DOTS etc) CDR has not been increased to that level. Actually it is only 36% in 2007. We therefore modified the target in a realistic way by aiming to achieve 70% by Year 5 of R8 (i.e. 2013).

Engage all health care providers - Strengthen PPM approaches

Raise TB awareness, build knowledge and create positive perceptions toward TB prevention, treatment efficacy and adherence, and reduce stigmatizing attitudes:

Sudan Tuberculosis



Value Year Source6 months 12 months 18 months 24 months Year 3 Year 4 Year 5

1.1 DOTS Expansion in war affected areas

Number of new TBMUs established inthe war affected areas

0 2008 NTP M&E Reports

9 14 19 24 29 Y N Y - over program term

UNDP


Number of TBMU staff trained from war affected areas

0 2008 Training records 36 56 76 96 116 Y N Y - over program term

NTP


Number of reported new smear postive TB cases from TBMUs in war affected areas

0 2008 R&R TB system, quarterly reports

270 270 270 270 270 270 N N N - not cumulative NTP

2.1 Improving diagnosis:case detection through quality assured microscopy

Number of zonal laboratories that are operational

0 2008 NTP M&E Reports

3 5 5 5 5 Y N N - not cumulative NTP

Monitoring and Evaluation

3.1 Establish MDR management Number of MDR-TB cases diagnosed


120 150 170 180 Y N Y - over program term

NTP

3.2 Ensure proper management for houshold TB contact tracing

Number of smear positive TB cases diagnosed among contacts tested


100 300 300 300 300 Y N N - not cumulative NTP

4.1 Engagment of other health careproviders in DOTS

Number of private health facilities that report to the NTP



NTP

4.2 Engagment of other health careproviders in DOTS

Number of public health facilities reporting to the NTP as DOTS link centers



NTP

5.1 ACSM (Advocacy, communication and social mobilization)

Number of community volunteers trained to support DOTS

0 2008 Training records 180 360 540 720 900 Y N Y - over program term

NGOs

5.2 ACSM (Advocacy, communication and social

Number of TB patients supported with income generation scheme

0 2008 Special Report on Income generation


STPA

Community TB care

Please Select… please select… Y N Y - over program term

Objective / Indicator Number

(e.g.: 1.1, 1.2)Targets for year 1 and year 2

I SUGGEST TO DELETE THIS. IT IS NOT EASY & ALMOST IMPOSSIBLE TO PREDICT THE NUMBER OF CASES TO BE DETECTED.

DTF: Name of PR responsible for

implementation of the

corresponding activity

Indicator Directly tied (Y/N)Annual targets for years 3, 4 and 5

Baselines included in

targets (Y/N)

4 staff per TBMU

Comments, methods and

frequency of data collection

Targets cumulative (Y-over program

term/Y-cumulative

annually/N-not cumulative)

Service Delivery Area Baseline (if applicable)

Sudan - Health Systems Strengthening: perfromance framework Sudan - Attachment A: Performance Framework (4b.2 -b-ii)

Sudan (Northern Sector)Tuberculosis (HSS)

12345

value Year Source Year 1 Year 2 Year 3 Year 4 Year 5

68 2006

WHO global TB report

66 64 62 59 56

419 2006WHO global TB report 406 394 382 363 345

36% 2007

R&R TB system, quarterly reports 40% 45% 50% 60% 70%

82% 2006 R&R TB system, quarterly reports 84% 85% 87% 87% 87%

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Objective Number

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

Although GF R5 target is to achieve CDR of 75% by Y4 of R5 (i.e. 2009) and maintain it to Y5 of R5 (i.e. 2010), because of the reasons mentioned in the proposal (i.e. access in war-affected areas, quality of DOTS etc) CDR has not been increased to that level. Actually it is only 36% in 2007. We therefore modified the target in a realistic way by aiming to achieve 70% by Year 5 of R8 (i.e. 2013).

please select…

Targets Comments*

Although GF R5 target is to reduce mortality to 40 per 100,000 by Y4 of R5 (i.e. 2009) and 35 by Y5 of R5 (i.e. 2010), because of the reasons mentioned in the proposal (i.e. access in war-affected areas, quality of DOTS etc) the mortality has not been reduced to that level. According to the WHO Global TB Report, it is still 68 in 2006. We therefore modified the target in a realistic way by applying 3% reduction from Y1to Y3 of R8 and 5% reduction from Y4 to Y5 of R8 (see the "Indicator calculation" worksheet).

3% reduction from Y1to Y3 of R8 and 5% reduction from Y4 to Y5 of R8 (see the "Indicator calculation" worksheet.

Although GF R5 target is to achieve TSR of 86% by Y4 of R5 (i.e. 2009) and maintain it to Y5 of R5 (i.e. 2010), because of the reasons mentioned in the proposal (i.e. access in war-affected areas, quality of DOTS etc) TSR has not been increased to that level. Actually it is 82% in 2007. We therefore modified the target in a realistic way by aiming to achieve 70% by Year 2 of R8 (i.e. 2010).

Strengthen health management information system, including surveillance and setting up a M&E system for measuring the health system’s performance

CommentsObjective description

* please specify source of measurement for indicator in case different to baseline source

GoalsTo improve the performance of national health system for a better response to the three diseases to achieve MDG-6

impact

Program Goal, impact and ouctome indicators



Build capacity of the system for drugs, supplies and equipment procurement and management, including quality assurance

Scale up, quantitatively and qualitatively, the availability of HRH at different levels of health care that it matches the basic standards

Strengthen health financing function of health system for assuring equity and access to health service

Program Objectives, Service Delivery Areas and Indicators

Improve health services delivery including laboratory services, assuring quality and equity of access at all levels of health care

Please Select…


outcome Case detection rate: new smear positive TB cases

Impact and outcome Indicators

TB mortality rate (all forms of TB)

Indicator

TB prevalence rate (all forms of TB)impact

Baseline


outcome


Treatment success rate: new smear positive TB cases



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Value Year Source6 months 12 months 18 months 24 months Year 3 Year 4 Year 5

1.1

HSS: Service delivery Number of locality health management teams organised and trained in basic management skills

0 2008

Training records

21 45 69 93 114

Y Y Y - over program term

UNDP/WHO

1.2

HSS: Service delivery Integrated health service package definedd for all categories of health facilities and job descripton for health staff developed

0 2008

Administrative records

Service package for all types of facilities

Job description for all health staff to provide integrated services


UNDP/WHO

1.3HSS: Service delivery Number of PHC and first referral

care health facilities furnished and equipped

0 2008Administrative records 30 60 90 120

Y N Y - over program term

UNDP/WHO

1.4

HSS: Service delivery Number of Rural and State Hospital laboratories upgraded to provide referral service, including for the three diseases

0 2008


19 38 57 76


UNDP/WHO

1.5HSS: Service delivery Number of community health

volunteers deployed to provde community and home-based care

0 2008Administrative records 200 400 600


UNDP/WHO

2.1

HSS: Information System

Number of localities where health facility staff trained in using tools of integrated health management information system

0 2008

Training records

25 100 134


UNDP/WHO

2.2

HSS: Information System

% PHC health facilities (average of northern states) which report regularly according to the stated national guidliens

35% 2008


45% 55% 75%


UNDP/WHO

2.3HSS: Information System

Number of man-month fellowships granted to M&E staff

0 2008Administrative records

15 36 60Y N Y - over program

termUNDP/WHO


Number of states producing annual report on health statistics and health system's performance



UNDP/WHO


Number of states having web link with national health information base and feed/retriev data

0 2008Administrative records 10 15


UNDP/WHO

3.1HSS: Medical Products, Vaccines and Technology

National essential drugs list and drugs formularies updated for the different levels of care

0 2008Administrative records 100%


UNDP/WHO

3.2

HSS: Medical Products, Vaccines and Technology

Number of states with an improved drugs’ inspection system operating according to standard guidelines

0 2008


4 8 12 15


UNDP/WHO

3.3


Standard treatment guidelines developed after adoption of a national policy and strategic plan on rational use of drugs

0 2008


A national policy and strategic plan on rational use of drugs

Standard treatment guidelines developed


UNDP/WHO

3.4HSS: Medical Products, Vaccines and Technology

Number of health managers at state/institution level oriented on health technology assessment

0 2008Training records


termUNDP/WHO

3.5


Number of states that have a comprehensive system for repair and maintenance of medical equipment

0 2008


5 10 15


UNDP/WHO

4.1

HSS: Health Workforce Number od State Health Academies rehabilitated, refurbished and provided essentail equipment

0 2008


8

N N Y - over program term

UNDP/WHO

4.2HSS: Health Workforce Continuing professional development

programme established in states 0 2008Administrative records 2 4


UNDP/WHO

4.3HSS: Health Workforce Number of PHC workers received

integrated on-job bridging courses to build/update knowledge & skills



termUNDP/WHO

4.4HSS: Health Workforce Number of community health

volunteers trained in two pilot states 0 2008Training records


termUNDP/WHO

4.5HSS: Health Workforce Number of HRH Directorates in

states that are operational0 2008


15Y N Y - over program

termUNDP/WHO

5.1

HSS: Financing National health accounts developed

0 2008


First NHA devloped through GAVI

NHA with sub-national accounts for the three diseases developed


UNDP/WHO Annual grant report, and structure built forfirst NHA developed by GAVI/HSS will continute to NHA and Sub-National Accounts

Target is for integrated HMIS, reported yearly as part of the system

There is some system that will be improved. Annual report and documentation

Comments, methods and frequency of data collection

Targets cumulative (Y-over program

term/Y-cumulative

annually/N-not cumulative)

Service Delivery Area

Reports produced annually by the states

Indicator Baseline (if applicable)

Annual grant reports from states compiled at national level

Directly tied (Y/N)Annual targets for years 3, 4 and 5

Baselines included in

targets (Y/N)

Annual grant report and copies of the service package and job descriptions

Objective / Indicator Number

(e.g.: 1.1, 1.2)

Targets for year 1 and year 2


Web surfing and annual grant progress reports

Grant progress report produced annually

DTF: Name of PR responsible for implementation

of the corresponding

activity


Annual grant reports from pilot states compiled at national Periodic reports from states compiled at national level

Annual grant report and copies of the documents

Annual grant report and copies of the documents

There exist a national EDL and formularies for some fcailitiesThere exists a weakly performing system of drug information

There is a partial input from GAVI/HSS and MDTF/DHSD project, progress reported Annual grant report and copies of training programs offeredIn addition, courses will be offered through GAVI/HSS.This is contingent on an associated activity of school rehabiltation Some states have rudimentary structure

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5.2

HSS: Financing Mechanism developed for equitable distribution of resources

0 2008


An approach, including a formual for equitable distribution

A sustainable health financing policy


UNDP/WHO

5.3HSS: Financing Number of man-month fellowships

granted to key health insurance staff at federal and state level


12 24 36 48Y N Y - over program

termUNDP/WHO

5.4HSS: Financing Number of states and localities'

health managers received short training in health economics


40 80 120 160 160Y N Y - over program

termUNDP/WHO

5.5HSS: Financing Number of state directorates of

health planning developing annual health plans



UNDP/WHO

Please Select… please select… Y N please select…Please Select… please select… Y N please select…Please Select… please select… Y N please select…Please Select… please select… Y N please select…Please Select… please select… Y N please select…

Annual grant report, and preparation made by GAVI/HSS will contribute in policy processAnnual grant report

Annual grant report

Annual grant report and copies of the document

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