WHO in Sudan: From Emergency to Sustainability WHO GENERIC DONOR REPORT

Transcription

1 WHO in Sudan: From Emergency to Sustainability WHO GENERIC DONOR REPORT January December 2005

2 Table of Contents I. Justification...3 II. Introduction...3 III. WHO and the humanitarian situation in Sudan Overall Darfur Kadugli transitional areas Kassala Eastern Sudan Khartoum...7 IV. WHO response Health Information and Coordination Management Improved Access to Hospital Care and Referral Services Communicable Disease Control, Surveillance and Outbreak Response Access to Primary Health Care, and Environmental Health Programme Management...34 V. Conclusion...35 VI. Annexes...37 World Health Organization 2

3 Justification It needs to be clarified beforehand that WHO Sudan activities do not include the programme activities falling under the WHO Southern Sudan office, based in Kenya, Nairobi. Introduction In appreciation of the continuous support received by a number of donors, this report is dedicated to the narration of the WHO activities in Sudan from January to December WHO Sudan humanitarian work has expanded from Darfur to other geographical areas in Sudan, with two new sub offices in Kadugli and Kassala. The emphasis lies on the transition from an emergency-focused operation to an established sustainable development programme. Long-term planning has become feasible thanks to the peace agreement between North and Southern Sudan, signed in January 2005, bringing an end to more than 20 years of civil war. WHO s main task is to provide other agencies with the necessary technical expertise, as well as the coordination of all health-related activities, in close collaboration with the Ministry of Health. Therefore, this report tries as much as possible to describe WHO Sudan s role within the broader context of the health sector in the Sudan. The report provides a description of WHO s activities. It explains the underlying rationale for the Organization s strategy and the division of its work programme into five sectors. An overview for each sector outlines the main achievements and the way forward for the future. Dr. Guido Sabatinelli WHO Representative in Sudan World Health Organization 3

4 I. WHO and the humanitarian situation in Sudan 1. Overall The peace agreement between North and South Sudan on 9 January 2005 brought an end to more than 20 years of civil war. This caused the emphasis of the humanitarian work in Sudan to change from an emergency response setting to a sustainable development programme. It is foreseen that a large part of the more than 4 million Internally Displaced Persons (IDPs) now living in temporary camps in Darfur, East Sudan and Khartoum are to return to their homes in Southern Sudan and those areas in between North and Southern Sudan, the socalled transitional areas. A returnees programme was initiated by the United Nations Country Team in Sudan, to properly prepare for the expected mass migration flux. WHO Sudan has expanded its humanitarian work accordingly. A new programme focused on the IDPs in Khartoum was initiated in the beginning of 2005, and two new offices were opened: one in May 2005 in Kassala, to cover Eastern Sudan, and one in August 2005 in Kadugli to cover the transitional areas. This chapter will describe the overall humanitarian situation in these areas. 2. Darfur The WHO programme in Darfur is deconcentrated over three sub offices, located in each of the capitals of the three Darfur States. Every sub office counts with a fully equipped office space, a warehouse, and a guest house for the international staff based in, or visiting Darfur. Three to four international staff members and between four and six national experts per office are maintaining the high quality work delivered since the beginning of the Darfur programme. In July 2005, a new field office was opened in Zalingei, West Darfur. The office supports, coordinates, and responds to the health needs of approximately 493,913 IDPs and war affected population in the nearby localities. While the number of IDPs in Darfur has been slightly decreasing in the last months of 2005, the total number of affected population has increased dramatically due to the intensified violent conflict between rebel groups. This has had a serious impact on the implementation of the planned programme activities in all of the Darfur States. Figure 1 provides an overview of UN estimates of the num ber of people displaced in Darfur since April i Figure 1: Estimated Number of IDPs in Darfur (UN estimates from April 2004 to November 2005) i Darfur Humanitarian Profile No November World Health Organization 4

5 Due to the ongoing conflict between rebel groups and related violence in Darfur, insecurity forms an important but limiting feature of the work. Rebel groups such as the Janjaweed attack civilians as well as government and humanitarian organizations, looting and stealing their properties. Roads become insecure to travel on and Minimum Operating Security Standard (MOSS) compliancy needs to be strictly applied. Where official security clearances are needed to travel within the government-controlled areas, those areas controlled by the Sudanese Liberation Army (SLA) need a different type of authorization by the SLA authorities. In spite of the difficult circumstances, humanitarian outreach and operational capacity in Darfur continues to grow in response to the rising numbers of affected populations. From 228 aid workers in April 2004, currently over 13,500 (national and international) humanitarians are active in the region with 82 NGOs and 13 UN agencies. Figure 2 shows the number of UN staff members and other humanitarian aid workers working in the three Darfur States as of 1 November ii Figure 2: Trends in Humanitarian Presence in Darfur: 1 April 2004 to 1 November 2005 The workload for the humanitarian community increased as a result of the growing number of conflict-affected population. Figure 3 shows the increase in number of people between January and October 2005 that were assisted in the key humanitarian sectors in Darfur, of which the majority are health related. iii Figure 3: Number of people assisted in key humanitarian sectors in Darfur January-October 2005 ii Darfur Humanitarian Profile No November iii ibidem World Health Organization 5

6 3. Kadugli transitional areas The transitional areas comprise of Blue Nile and South Kordofan State/Nuba Mountains and Abyei with an estimated total population of 3.9 million. The region is geographically and politically divided between Government of Sudan (GoS) and Sudan People s Liberation Movement/Army (SPLM/A) control. As outlined in the Comprehensive Peace Agreement (CPA) iv, with the installation of the new Government of National Unity on 9 July 2005, an Interim Period of six years was initiated. In this Interim Period, the region will have alternating SPLM/A and GoS rule until a unique referendum is held for the State to decide upon its future, affecting the health system in the whole region and specifically Abyei. As health care policies are developed at state level, the health system will be subject to a high degree of changeability until after the referendum. The office in Kadugli focuses on the coordination of humanitarian assistance in the health sector by improving information sharing and decision-oriented health coordination meetings. The reduction of mortality and morbidity is the overall goal, by ensuring the provision of quality Primary Health Care services. One of the specificities of the work in the transitional areas are the so-called way stations. These have been established at strategic points along the main routes IDPs returning home are expected to take. Way stations are providing limited and short-term health and other assistance, set up and managed by NGOs. Three international health professionals and three national experts embody the office in Kadugli, which also functions as a guesthouse. A field office will be opened in Abyei. Communication problems such as limited cellular phone coverage, telephone and internet connection are currently being taken care of. 4. Kassala Eastern Sudan East Sudan region is comprised of the Gedaref, Kassala and Red Sea States, with an estimated population of 3.9 million. The region hosts around 63,000 IDPs in Kassala State, an additional several thousands in Port Sudan and 90,000 camp-based Eritrean refugees. Armed conflict has been present in the region since the mid-1990 s. Late January 2005, the security situation deteriorated and resulted in temporary suspensions of access of UN staff between Port Sudan and Kassala, and IDPs and refugee camps near Kassala town. The continuing poor relations between the GoS and the Eritrean Government (being accused of providing assistance to some eastern-based opposition forces), as well as the increasing tension between Eritrea and Ethiopia, are increasing the risks of potential conflict in East Sudan that will result in an increase of population movements and influx of refugees. Potential flooding in Kassala State also remains a concern. In July 2003, heavy rains in Ethiopia, Eritrea and Eastern Sudan caused the rupture of the Gash River banks leaving about 17,000 households homeless. One international public health expert and one national expert are working in the office in Kassala, which also functions as a guesthouse. iv The Comprehensive Peace Agreement (CPA) is a series of agreements and protocols that have been negotiated between the Government of Sudan and the Sudan Peoples Liberation Movement World Health Organization 6

7 5. Khartoum The IDP population in and around Khartoum is estimated at 2.1 million, of which around 325,000 are residing in four official camps and the remaining population in approximately 30 different settlements (called squatter areas). However, the estimated caseload of IDP is constantly fluctuating because of ongoing demolitions, IDP resettlement, rezoning and return. The process by which demolition, relocation and plot allocation and forced return have been undertaken in some cases have been classified by the UNRC as human rights violations,. The health challenge in Khartoum is to improve basic health services that have been deteriorating for the last several years with the withdrawal of most international agencies, including UN agencies. Meanwhile, specific health activities should be assured and provided to IDPs willing to return to their areas of origin. One international and one national public health expert are working on the IDP programme in Khartoum, from the WHO premises in the capital. World Health Organization 7

8 II. WHO response 1. Health Information and Coordination Management The main objective of the health information and coordination management programme area is to support the Federal Ministry of Health (FMoH) and State Ministries of Health (SMoH) in the provision of high quality health care by ensuring good partnership and collaboration between all health institutions. Through weekly health coordination meetings at the decentralized level, and bi-weekly meetings at Khartoum level, all health partners share information on their main activities. These meetings are chaired by SMoH and FMoH respectively, with WHO support. The overall goal of coordination in the humanitarian setting is to ensure continuity of health provision in those areas dependent on temporary health centres set up by Non Governmental Organizations (NGOs). Due to the excellent relationship with NGOs, WHO has become the indispensable tie between the Ministry of Health and NGOs on any health related issue. The same counts for other UN agencies working in health like UNICEF, UNFPA, UNAIDS and WFP, as well as for the United Nations Peace Keeping Mission in Sudan, UNMIS. Within the UN system in Sudan, WHO has the mandate to coordinate all overall health related matters. Specific health subjects like water and sanitation and primary health care fall under the responsibility of UNICEF and reproductive health issues are the responsibility of UNFPA. To further facilitate the coordination of the health sector, WHO ensures the dissemination of relevant and appropriate information to all stakeholders. Weekly and monthly reports are advocating for appropriate best practice, while technical guidelines are fostering consensus on the standardization of protocols, definitions, and forms. Updated GIS-plotted maps are produced on a regular and as needed basis. All information is made widely available on the WHO Sudan website at a. Achievements The health coordination meetings have become an excellent institutionalized means in keeping all stakeholders up to date of all relevant ongoing health activities. As WHO presence in Darfur has been established much earlier than in Kassala and Kadugli, the meetings there have become more focused on decision-making, demonstrating the increasing ownership of SMoH staff chairing the meetings. Under the responsibility of the Primary Health Care (PHC) Directorate of the SMoH in each of the three Darfur States, interagency PHC task forces have been set up in order to enhance efforts in jointly assessing and monitoring health facilities for quality services to IDPs. Members of the task force are SMoH, WHO, UNICEF, UNFPA and several NGOs. One of the major achievements in the PHC area is the elaboration and maintenance of the so-called health matrix. In all States where WHO has representation, it is WHO responsibility to contact all health partners and inventory their health facilities, their activities, and geographical coverage, in close collaboration with the PHC task force. The activities that are inventoried in the health matrix vary from basic health care to reproductive health care, from the number of latrines available to the number of mosquito bed nets used, from water and sanitation to epidemiological surveillance, from laboratory capacity to available vaccines and cold chain, from pharmaceutical capacity to supplementary nutrition, etc. Furthermore, the capacity of the health centre itself is considered, looking at the number of beds, the opening hours, as well as the number of health staff and their skills and training. World Health Organization 8

9 To maintain a minimum standard of quality, all health facilities are assessed and monitored on a regular basis. The PHC task force implements this task using a standardized form that has been tested and agreed on by all health partners. Since the opening of the WHO office in Kassala in May 2005, 81 health facilities have been evaluated in the whole of Kassala State. WHO Kadugli inventoried 252 health facilities in South Kordofan, of which approximately 25% had been assessed by the end of The health matrix facilitates the identification of gaps: those areas that remain uncovered by sufficient basic or specialized health care. At WHO Sudan, one of the informal underlying goals is to fill the gaps. On an as needed basis, agreements with NGOs are made to provide health services in areas with low coverage. In Darfur, the SLA-controlled areas are chronically underserved due to the high level of insecurity. Also in the three Darfur States, bi-weekly Nutritional sector meetings and weekly Reproductive Health meetings are held at respectively the SMoH and UNFPA. In Reproductive Health, the adaptation to local standards of the WHO guidelines on Making Pregnancy Safer has significantly improved the quality of care during pregnancy and childbirth as well as for newborns. In Darfur, Kassala and Kadugli, disease outbreak task force meetings jointly organised by SMoH, WHO and other health partners, were organized to monitor and control all suspected cases as well as the alarming increase in number of cases of all infectious diseases. The protocols and procedures for treatment of Hepatitis E, Cholera, Dysentery caused by Shigellae species, Meningococcal Meningitis and Common Diseases, and the indicators for quality of Primary Health Care provision were elaborated by consensus and have become the main reference material on the diagnosis and treatment of the respective diseases for SMoH, UN agencies and NGOs in all of the Darfur states. Current guidelines agreed to by MOH available according to demands of NGOs and clinics in both English and Arabic languages. Fact sheets on Dengue and Dengue Hemorrhagic fever and Yellow Fever were elaborated and disseminated after suspected cases of these diseases where reported. (See chapter 3) The Inter-Agency Technical Advisory Group (IATAG) aims to provide technical guidance to UNICEF for coordination of the Water and Sanitation sector. The group is led by UNICEF and consists of WHO and the Humanitarian Information Centre (HIC) of the UN Office for Coordination of Humanitarian Affairs (OCHA), the NGO Oxfam, the International Committee of the Red Cross (ICRC), the donor agencies USAID and DFID, as well as the Water and Environmental Sanitation (WES) department and the National Water Corporation. Several joint assessments were conducted with other UN agencies, SMoH and NGOs. Achievements of assessments are sometimes difficult to indicate. One Food Security Assessment in West Darfur, which verified an increased number of cases of severe malnutrition in Saraf Jedad in Serba concluded that the communities had received General Food Distribution (GFD) and were as a result added to the WFP food distribution list. The number of cases of severe malnutrition decreased as a result of the assessment. The Crude Mortality Survey 2005 for Darfur was a joint effort between the UN system and the Government of Sudan, as well as all NGOs, reflected in both the preparations as well as the implementation of the survey at field level. The implementation of the survey is an excellent example of technical support provided to FMoH and SMoH. Sound epidemiological training on the survey s methodology was conducted to the national supervisors, whom were all able to apply their knowledge in the field under the supervision of international epidemiologists and public health experts. More on the Crude Mortality Survey in chapter 3. World Health Organization 9

10 WHO Sudan shares its information openly and widely with its stakeholders. Where political sensitivity is involved, such as with the results of the Crude Mortality Survey, the appropriate prudence is taken into account. WHO aims to be a transparent organization, and is fully aware of the fact that its products are of use to many. All information products are therefore made widely available to the public through the website as well as through electronic distribution lists. The Documentation Centre at the WHO premises is another way of increasing the availability to the information, especially of those groups who do not have access to internet. b. Way forward for 2006 The need to further improve coordination and information sharing: This is a recurring lesson, but it is particularly relevant in view of the potential major changes in the political and humanitarian situation in Sudan in 2005 that might result either from an increase in conflict or the conclusion of an overall peace agreement. Such changes will require increased inter-country coordination and new information-sharing on cross-line arrangements, demobilization and return flows, among others. The need to strengthen team work: WHO, UNICEF and UNFPA must continue to strengthen interaction and collaboration to promote the implementation of a common UN system approach across Sudan and to play an effective leadership and advocacy role. The need for decentralization Further training and monitoring of Camp Health Coordinators on the common and standard approach of assessing, analyzing and planning health interventions that were planned for May, have been postponed to June because of other activities being prioritised at sub office level. WHO, SMoH, the Water and Environmental Sanitation department (WES), and UNICEF are collaborating in their efforts to implement Health Coordination and Environmental Group meetings at camp level. The need for information in Arabic Current guidelines will be made available in both English and Arabic languages. World Health Organization 10

11 2. Improved Access to Hospital Care and Referral Services The pressing need for quality secondary health care became imminent immediately after the beginning of the Darfur crisis early The hospitals in Darfur were desperately unprepared for the large influx of people requiring emergency care. For the first time in WHO history, WHO Sudan initiated a hospital programme aiming at the waiver free treatment for IDPs and conflict-affected populations. This hospital programme consists of the physical rehabilitation of the main departments of the most important hospitals in Darfur, as well as the payment of incentives of staff and running costs of the hospitals related to the IDPs, and the supply of essential drugs for the main treatments received by IDPs. An additional way to support the hospitals is through training and capacity building of the hospital staff. Hospital management staff has been involved in several training activities, focusing on the improvement of management and financial administrative systems. All hospital pharmacies have been subject to the implementation of an effective pharmaceutical management programme, including high level training. Laboratory technicians have been trained continuously according to the arising needs for several types of laboratory testing, such as HIV/AIDS, Malaria, etcetera. Management of hospital waste is also an important aspect of the hospital programme, however falls mainly under the environmental health programme, as described in chapter 5. One year after the initiation of the hospital programme, it became clear that its sustainability was at stake. If WHO would cease the payments and drugs supplies to the hospitals, they would be unable or unwilling to provide waiver free treatment to IDPs. As the IDP problem persists in Darfur, an alternative solution had to be found. In search of a sustainable solution for the hospital programme in Darfur, hospital-related activities in Kassala and Kadugli have been limited to very specific actions, such as the support of the painting of the nursing school in Kassala Teaching Hospital or the rehabilitation of Voluntary Counselling and Testing centres for HIV/AIDS in Kassala. a. Achievements So far, 75% of all accessible hospitals have been rehabilitated, with 12 out of 23 (of which 15 are accessible) providing free access to IDPs. While the rehabilitation of the hospitals in 2004 was focusing on departments such as the emergency obstetrics and the operating theatre, the rehabilitation activities in 2005 focused on the laboratory, the blood bank and the water system. The rehabilitation of the three central laboratories in El Fasher Teaching Hospital, North Darfur, was completed and the laboratories are now fully operational. After the renovation of the blood bank, high sensitivity Hepatitis B, C, and HIV screening tests are carried out on all donated and transfused blood, to decrease the risk of blood borne contagions. For the improvement of the sewage system, 25 septic tanks have been reconstructed and all wells have been cleaned. Currently, the renovation of a paediatric and the second surgical ward at the El Fasher Teaching Hospital is ongoing. In West Darfur, WHO rehabilitated the laboratory, blood bank, gynaecology, female surgical and medical wards of El Geneina State Hospital and contributed with a generator, electrical goods and furniture. In Habila Hospital, WHO rehabilitated the laboratory and blood bank. Additional works on the laboratory and blood bank are currently ongoing to meet the international standards. World Health Organization 11

12 The rehabilitation of the water system of El Geneina Hospital is another innovate project and includes the construction of two main wastewater collection pipelines and a large soak pit. This newly constructed drainage system aims to improve the overall environmental health conditions in the hospital. The medical wards and ophthalmology department at the El Geneina Hospital have also been refurbished. The rehabilitation of the outpatient department of Nyala Teaching Hospital was completed, as well as one surgical ward, the kitchen, and the X-ray department. WHO provided the hospital with orthopaedic instruments. Preparations are underway for the rehabilitation of the intensive care unit (ICU) and the pharmacy at Nyala Teaching Hospital. Kass and Eldaien Hospitals in South Darfur have been totally rehabilitated. The main areas that have been renovated in Kass are the water supply and wastewater disposal as well as at the outpatient department. Each sub office in Darfur counts with a national hospital focal point who interacts closely with the local hospital focal point within the hospital. One overall national expert on secondary health care facilities and hospital rehabilitation based in Khartoum is overseeing and coordinating all activities within the hospital programme in Darfur. To formalize all ongoing activities with the hospitals in Darfur, Technical Coordination Agreements (TCAs) are signed between WHO, SMoH and hospital management. The TCAs describe in detail the specifics of the support provided by WHO to the hospitals and the responsibility the hospital has concerning the provision of waiver free treatment to IDPs. Figure 4 gives an overview of the percentage of IDPs treated at the different hospitals in Darfur WHO has signed TCAs with. According to the TCAs, WHO provides the hospitals with recurrent costs, incentives for staff and a monthly delivery of free drugs and medical supplies, as to compensate that the IDPs can receive free treatment and drugs. Only for the main hospitals in Darfur statistical data are available. The percentage of IDPs in El Fasher Teaching Hospital is significantly lower in all of the three departments than in the two other main hospitals in Darfur. El Geneina Hospital in West Darfur treats the largest 100% Figure 4: percentage of IDPs and non-idps treated in Darfur hospitals 80% 60% 40% 20% 0% Percentage of non IDP patients OPD IPD OT OPD IPD OT OPD IPD OT Fasher Geneina Nyala OPD = Out Patient Department IPD = In Patient Department OT = Operating Theatre Percentage of IDPs percentage of IDPs in all of the three departments. This may be explained by the relatively small total number of patients treated at El Geneina Hospital: only 928 patients were treated in El Geneina Hospital in July 2005 (761 in June 2005), of which 556 were IDPs. The total number of patients treated in Nyala Teaching Hospital for the same period was 5,932 and El Fasher Teaching Hospital 2,345. A large number of IDPs is treated at the Inpatient Department and the Operating Theatre of Nyala Teaching Hospital due to the proximity of the largest IDP camp in South Darfur to the hospital: Kalma IDP camp (with a population of approximately 130,000 v ). v Darfur Humanitarian Profile No August 2005 World Health Organization 12

13 For further insight in the kind of treatments received by IDPs and non-idps at the Darfur hospitals, the following figure gives the percentages of the ten most received treatments in El Fasher Teaching Hospital in North Darfur for the months January to May Figure 5: ten most received treatments at El Fasher Teaching Hospital from January to May % 80% 60% 40% 20% 0% Jan Feb Mar Apr May Skin infection Gastroenteritis & Diarrhea Tonsillitis Malnutrition Ear diseases Disease of Teeth Trauma & Injuries Malaria Respiratory Tract Infection To enable the hospitals in treating IDPs at no-fee basis, WHO compensates the hospitals with monthly payments for running costs, incentives for staff and delivery of essential drugs. As shown in Figure 5, the total amount of money paid to the hospitals is in relation to the number of IDPs treated at the hospital. Figure 6: total amount of money paid and total number of IDPs treated during July 2005 at Darfur hospitals Total monthly payment IDPs monthly payment in USD $60,000 $50,000 $40,000 $30,000 $20,000 $10,000 $0 Fasher Geneina Nyala 2,000 1,800 1,600 1,400 1,200 1, total number of IDPs treated For all hospitals in Greater Darfur the following amounts are paid on a monthly basis to the hospitals based on the TCAs, as shown in the following table. Table 1: WHO payment in US dollars to hospitals in Greater Darfur during all months of 2005 North West South Running cost Incentives Drugs El Fasher Teaching Hospital 3,700 3,300 25,000 Maternity Hospital 2,000-4,000 Kutum Hospital - 1,000 4,000 El Geneina Hospital 8,000 4,000 25,500 Zalingei Hospital 4,000-7,500 Fur Baranga Hospital 1,500-4,000 Kulbus Hospital 2,000-3,000 Nyala Teaching Hospital 15,000 13,000 25,000 Elddain Hospital 5,000 7,000 7,500 Kass Hospital 3,000 4,000 7,500 World Health Organization 13

14 Incentives for the staff In the beginning of the hospital programme, only key staff at key services (the outpatient department, operating theatre and surgical ward) was paid incentives. This unfortunately had a negative impact on the overall general performance within the hospital. The policy was then modified into supporting the post or function, and not the personnel. All staff had to have the possibility to participate in the incentives system. Also, incentives could only be paid on a shift basis. The number of posts within the second health care facility was based on Sphere standards vi : 1 nurse every 8 hours for 20 beds 1 doctor per 50 consultations in outpatient department By using the hospital statistical data and the assessment report, the number of the posts could be identified The rate of the incentives had to be estimated depending on basic salaries received from the Ministry of Health, and the current incentives scale for health workers per state. This was taken into consideration per post, not per individual. Incentives are only paid against a certain standard of performance and job description, and as part of the signed TCA with the hospital. A joint monitoring of performance is done by the medical director of the hospital and the WHO Focal Point on a daily basis. To ensure transparency, the end results of the monitoring are made available to all staff. The revision of the process is done on a monthly basis. There was a need to increase the number of posts in order to cope with the workload, especially for those hospitals in migration corridors. Running costs The running costs were identified by studying the budget of the hospital and the expenditures over a minimum period of 6 months per hospital. To assure reliability of the end data, only the most reliable data were used. The financial data were matched with the hospital statistics and the workload, taking into consideration the oscillation of conflict and population movement. The main fields which affected the service provision for IDPs were identified as fuel for the generator, water supply, telephone calls, fuel for ambulance vehicles, stationary and printing materials such as patient files, and essential maintenance costs for recruitment and furniture in the hospital. The hospitals make requests to fund certain activities, which need to be approved by the WHO focal point. The money is transferred directly to the hospital bank account against a documented receipt and a report from the focal point. Provision of drugs and supplies According to the rational use of drugs policy, the ceiling of the amount of drugs to be received by the hospital depends on the IDP workload, the workload caused by the amount of emergency cases and the morbidity and mortality data on a 3-months basis. Within the WHO initiative on Rational Use of Drugs, the National List of Essential Drugs was distributed to all the hospitals in Darfur, while a central medical supplier was nominated and an active quality control system was put in place. The drugs/medical consumables needs for the main and rural hospitals are inventoried and requested per three months. WHO organized three successful seminars in close collaboration with FMoH and SMoH on the revised Sudan National List of Essential Drugs all of the Darfur States. A total of 89 participants including health providers from the NGO community attended the seminars attended the seminar. vi World Health Organization 14

15 An effective and efficient pharmaceutical inventory management tool was set up at El Geneina hospital and El Fasher Teaching Hospital and is fully utilized by the pharmacy staff. Main objective is to monitor the drug use and the storage system in the hospital. Due to the efficient management of the drugs/consumables, the stock of the drugs/consumables delivered in January 2005 that were meant for only one month were still being made use of in May. Hospital management boards were set up in Nyala, Kass, Elddain, El Geneina Hospitals through on the job training on coordination and auditing skills. A hospital coordination meeting was institutionalized in each state. To improve the hospitals health information systems, desktops were purchased. The software system used in the hospitals was adapted to include IDP data. Training of Trainers (TOT) and workshops on basic nursing skills, hygienic precaution and infection control were held throughout the Darfur States. 45 new trainers and 120 nurses were trained in the Darfur States. Further training on emergency treatment, war surgery and others have been conducted continuously throughout the year. Special support was given to the Maternity Hospital in El Fasher, after severe flooding damaged an important part of the hospital. Sand bags were provided, as a temporary solution for future flood-prevention. Furthermore, Italian trauma kits, New Emergency Health Kits, Cholera Kits, Malaria treatment drugs Artesunate and Sulfadoxine Pyrimethamine (SP), and rapid malaria testing material Paracheck were delivered to various rural hospitals. The same material is prepositioned at the WHO warehouses in the three Darfur States. In collaboration with the Global Fund for Aids, Tuberculosis and Malaria (GFATM) and FMoH, WHO has provided the hospitals with blood bank reagents. The services of local HIV/AIDS and Gender-Based Violence (GBV) counsellors were provided, together with equipment for emergency obstetrics, paediatrics, and trauma surgery in refurbished facilities. Kassala rehabilitated 3 VCT centres and provided training for VCT counsellors. b. Way forward for 2006 Although plans to implement an insurance based system (Fees for Service) mechanism to ensure free access of IDPs are being designed, no concrete proposal has yet been concretized. The idea is create an IDP cost tracking system focusing on post-service payment as a transitional stage towards a health insurance based system. Once the physical rehabilitation of the health facilities, including the establishment of a professional health information management system and of a drug supplies inventory system is completed, the focus will shift on capacity building in hospital management. WHO will look into the possibility to strengthen the implementation of the efficient pharmaceutical inventory system in the Darfur hospitals. Drug Use Surveys will be carried out to study the extent to which prescribers in the main hospitals in Greater Darfur are prescribing drugs from the Sudan National List of Essential Drugs. World Health Organization 15

16 3. Communicable Disease Control, Surveillance and Outbreak Response The Darfur-wide Early Warning Surveillance System (EWARS) has proven a highly effective tool for outbreak alert, investigation, and verification. The weekly collection of epidemiological data from all health facilities attending the conflict-affected population in Darfur, presented in the Weekly Morbidity and Mortality Bulletin (WMMB), provides a good overview of the ongoing trends in the main diseases. Rapid response to anomalies is made possible thanks to the collaboration of all health partners and the analysis of data at State and national level. A good level of preparedness is ensured through the pre-positioning of essential supplies (drugs and consumables) for outbreak control and the development of necessary plans for outbreak prone-diseases, such as cholera and meningitis. To ensure rapid laboratory verification of samples of suspected cases, transport media and a functioning referral chain to the National public Health Laboratory (NPHL) are made available. Targeted vaccination programmes are carried out as appropriate to prevent further spreading of vaccine-preventable diseases that can cause high level of morbidity in crowded conditions such as IDP camps. Furthermore, the communicable diseases programme works closely together with the environmental health and vector control programmes to effectively respond to water-borne and vector-borne disease outbreaks. a. Achievements Early Warning and Response Surveillance system (EWARS) The maintenance of the EWARS system has been a true challenge because of encountered communication problems and limitations due to insecurity. In spite of these difficulties, EWARS has managed to expand the number of reporting units on a weekly basis to 126 in December 2005, compared to 79 units in December of The higher the number of reporting units, the more representative the data, as the number of consultations increases. The addition of reporting units to the system implies training on EWARS of the health staff involved in the collection of the data. The availability of communication means to consistently report the statistics remains the most serious weakness. All health facilities that participate and collaborate in EWARS by providing their health statistics to SMoH and WHO, are grateful to receive the Weekly Morbidity and Mortality Bulletin (WMMB), that provides them with good insights of the overall health condition in the whole of Darfur. The WMMB is elaborated at Khartoum level between WHO and FMoH, as well as at State level, between WHO and SMoH. Thanks to EWARS, up to date information on outbreaks or predictions of risks of outbreaks is readily available. Every suspected case of highly infectious diseases such as Acute Watery Diarrhoea, Meningitis, and Measles, as well as an alarming increase in number of cases, is investigated. Many times the outbreak investigation concludes that an alarming increase in cases is due to over-reporting or under-calculation of the population. Training of health staff in standardized case definitions has proven effective in these situations. For example, in May 2005 a number of clinically diagnosed Leishmania cases were reported from El Malha, North Darfur. A rapid assessment team from the FMoH Leishmania Eradication Program, SMoH and WHO could confirm only 2 out of 25 cases. Subsequently a standard case definition to aid examination of suspected cases was provided. Also, medical assistants and nurse from Malha IDP camp were trained in Leishmaniasis case management, referral, and follow-up of patients World Health Organization 16

17 Another frequent cause of increase in cases is due to bacteriological contamination of drinking water in IDP camps, resulting in water-borne diseases such as Hepatitis E, Bloody Diarrhoea, and others. Improvement of the drinking water quality and the sanitary conditions of the population has a direct impact on the incidence of these diseases. WHO is currently implementing a system to quantify the relationship between water-borne diseases and chlorination of drinking water in IDP camps, as well as between vector-borne diseases and vector control campaigns (i.e. spraying and fogging as well as the distribution of mosquito bed nets). Thanks to the continuous increase in reporting units, EWARS reported a total number of 3,229,160 consultations in Darfur during As shown in Figure 7, the main categorized causes for consultation are Acute Respiratory Infections (ARI) with 17%, Malaria (MAL) with 7% and Bloody Diarrhoea (BD) and Injuries (INJ) both with 3%. Other causes are Fever of Unknown Origin (FUO) with 2% and Acute Jaundice Syndrome (AJS) with 1%. The main causes of deaths are also due to Acute Respiratory Infections, Malaria and Bloody Diarrhoea. Figure 7. Main causes of consultations in Darfur for 2005 ARI 17% BD 3% INJ 3% AJS 1% OTH 67% MAL 7% FUO 2% (Cases inclusive of deaths n = 3,229,160) Figure 8 on the following page shows that the majority of cases were reported from South Darfur, while the majority of deaths were reported from West Darfur. South Darfur is the State with the largest number of IDPs in camps, all covered by primary health care facilities. This may explain the high number of consultations in South Darfur. The large number of deaths in West Darfur can be explained by the enhancement in the collection of data that has taken place throughout the year Figure 8. Percentage of cases and deaths among the three States of Darfur for % 75% 50% south west north 25% 0% cases deaths World Health Organization 17

18 Of the total number of cases, the majority (63%) was among the above 5 years of age group. Similarly, of the total number of deaths, 60% was among the above 5 years of age group. (See Figure 9) Figure 9. Total number of cases and deaths for above 5 and under 5 years of age in Darfur for ,100,000 1,800,000 1,500,000 1,200, , , ,000 0 cases deaths under 5 above 5 1,600 1, From comparisons between 2004 and 2005, it is clear that the health situation of the conflict affected population in Darfur in 2005 is much improved compared with the same period in As the EWARS system was set up in epidemiological week 21 of 2004, it needs to be taken into account that due to adaptation problems, the epidemiological data in the first 4 weeks after the implementation of EWARS may not be accurate. The following paragraphs will explain the trend in the major diseases in Darfur, starting with the three main diseases: Acute Respiratory Infections, Bloody Diarrhoea and Malaria. Acute Respiratory Infections The total number of cases due to ARI in 2005 is 553,215, with 120 related deaths. (See Figure 10) The overall Case Fatality Rate for 2005 was 0.02%. Although the number of cases remains high throughout the year, the number of deaths decreased as of week 46. The low number of cases in week 44 can be explained due to the Eid holidays, when the number of reporting units dropped significantly when compared with other weeks. Figure 10. Total number of cases and deaths for ARI, Darfur, 1 January-31 December 2005 Number of cases 20,000 15,000 10,000 5,000 0 cases (n=553,215) deaths (n=120) Number of death Bloody Diarrhoea The total number of cases due to Bloody Diarrhoea in 2005 is 102,154 with 113 related deaths. The overall Case Fatality Rate for 2005 was 0.11%. A comparison made between 2004 and 2005 shows a significant decrease in attack rate of Bloody Diarrhoea. (See Figure 11 on the following page) The weekly attack rate in 2005 shows a gradually decreasing trend. Bloody Diarrhoea remains a major concern in the health situation in Darfur. This is directly related to the quality of drinking water and the sanitary measures taken in the IDP camps. WHO aims to tackle the continuous high number of Bloody Diarrhoea cases by methodically improving the environmental health conditions in the IDP camps. WHO advocates for frequent chlorination of appropriate level. World Health Organization 18

19 Figure 11. Weekly attack rates of Bloody Diarrhoea Greater Darfur, 2004 and 2005 Attack rate per 10, Week Cholera Due to the vastly improved environmental health situation, no cases of Acute Watery Diarrhoea (or Cholera) were reported through the EWARS system during the whole of To reduce the risk for a Cholera outbreak to occur and to prepare for such an event, Cholera preparedness and response plans for Darfur were finalized and widely disseminated. Microplans were elaborated for effective Cholera outbreak management and control at both State and camp level. The Cholera Outbreak Task Force, led by WHO and UNICEF and comprising of SMoH, WES, and all NGOs working in environmental health issues, were reinforced in preparedness for the rainy season. Cholera kits were prepositioned in those IDP camps selected as focal centres for Cholera Outbreak Control because of their high population density, morbidity and mortality of water related diseases, as well as water and sanitation indicators. Essential laboratory supplies, Intravenous fluids, Oral Rehydration Salts are part of the kits. Hepatitis E The total number of cases due to Hepatitis E in Darfur in 2005 was 17,643 with 66 related deaths. The overall Case Fatality Rate for 2005 was 0.37%. This shows a vast reduction when comparing to the Case Fatality Rate for Hepatitis E for 2004 (between 22 May and 31 December 2004), which was 0.94%. A comparison made between 2004 and 2005 shows a significant decrease in attack rate of Hepatitis E. (See Figure 12) Figure 12. Weekly attack rates of Hepatitis E, Greater Darfur, 2004 and 2005 Attack rate per 10, Week Case investigation was carried out into the continuously increasing number of cases of Acute Jaundice Syndrome (related to Hepatitis E) in Mukjar, West Darfur. A UNICEF report suggested faecal-oral contamination of water sources as people still collect water from the Wadi instead from chlorinated hand pumps. Only one blood sample out of 9 could be tested for ELISA and Hepatitis E was laboratory confirmed. Malaria The total number of cases of Malaria in Darfur in 2005 is 227,550 with 211 related deaths. The overall Case Fatality Rate for 2005 was 0.09%. This shows a vast reduction when comparing to the Case Fatality Rate for Malaria for 2004 (between 22 May and 31 December 2004), which was 0.19%. Comparing the weekly attack rate for 2004 and 2005, as shown in Figure 13 on the following page, it can be stated that Malaria control has significantly improved since last year. World Health Organization 19

20 Figure 13. Weekly attack rates of Malaria, Greater Darfur, 2004 and 2005 Attack rate per 1, Week Malaria preparedness and response plans for Darfur were finalized and widely disseminated in preparation for the rainy season. WHO donated a large number of Rapid Diagnostic Tests (RDTs) for Malaria and other basic drugs and medical supplies to the UNMIS clinics and to NGOs working in IDP camps in Darfur. The indicator for a successful Malaria preparedness programme is the distribution of insecticide treated mosquito nets to 1,500,000 people, representing 60% of the total estimated population of 2,500,000. Between January and July 2005 a total of 167,508 mosquito nets were distributed. With still 10,055 nets in warehouse and another 50,000 ordered and awaited, the total number of nets available covers only 15.2% of the estimated 60% of the total population. The lack of insecticide for net treatment (K-O tab, or deltamethrin SC formulation) delayed the treatment of 60,000 mosquito nets in Zalingei, West Darfur. Vector control spraying campaigns are carried out mainly though NGOs, such as the NGO IRC who is taking the lead in vector control in IDP camps in Kass Locality, South Darfur through organizing partners to participate in vector control activities. WHO provides equipment and insecticide Indoor residual spraying (IRS) coupled with space spraying was carried out in IDP camps in all three states to protect people from malaria mosquito bites. Synthetic pyrethroid insecticides were used during spraying. Mosquito larvae were controlled through destruction of breeding sites (draining water collections and/or covering breeding places) and through spraying of used engine oil on breeding places. An impressive consignment of antimalaria drugs was received from the Global Fund for Aids, Tuberculosis, and Malaria, channeled through WHO. The drugs supply of more than 2 million boxes of artemisinin-based combination therapies (ACTs), the most effective antimalarial drugs available today will cover a total population of over 17 million people in the 10 States of Kassala, Gedarif, Sinnar/South Gezeira, White Nile, North, South and West Kordofan, West and South Darfur, West Bahr el Ghazal, and Bahr El Gabal. Over 6 million USD was received from the GFATM on drugs and other medical supplies. In June 2005, the Director of National Roll Back Malaria (RBM) program conducted training in West Darfur on the malaria treatment protocol for laboratory technicians. All participating health partners developed an integrated workplan for malaria interventions. In South Darfur, medical assistants and community health workers corridor were trained on providing ACT according to the national Malaria protocol. In Eastern Sudan (Kassala, Red Sea and Gedaref States) an intense Malaria prevention programme was carried out. A total of 260 medical assistants and doctors were trained in the new Malaria treatment protocol and Malaria case management, 100 laboratory technicians were trained on Malaria microscopy as well as almost a 100 sprayers for vector control campaigns. Furthermore, training on Malaria prophylaxis in pregnant women and Dengue fever case management was carried out for midwives and medical assistants. World Health Organization 20

21 Measles The total number of cases of Measles in Darfur in 2005 is 417 with no related deaths. (See Figure 15) Over 50% of the total cases were reported from West Darfur. Figure 15. Measles cases and deaths, Greater Darfur, 1 January-31 December 2005 No. of cases Cases (n=410) Deaths (n=0) Week Compared to 2004, where 1,059 cases of Measles were reported with 43 related deaths (Case Fatality Rate of 4.1%) this means a significant improvement. Taken into account that the population under surveillance and the number of consultations has more than doubled when comparing July 2004 with July 2005, Figure 16 shows that the number of reported Measles cases and related deaths has decreased dramatically. Figure 16: Measles cases and deaths, Greater Darfur, month of July Cases Deaths total number Due to continued transmission of the Measles virus in all three states of Darfur, a series of localized Measles vaccination campaigns was carried by MSF-Holland in cooperation with SMoH, WHO and other NGOs: In Ganderni, Morni Administrative Unit, West Darfur (3,390 children between 9 months and 15 years of age) in March 2005; In Thur locality, South Darfur (4,686 children between 9 months and 15 years of age) in April 2005 in Kalma, Kass and El Seref IDP camps in South Darfur in June 2005 A mass Measles vaccination campaign was carried out in Darfur in phases. In August in South Darfur, a total of 608,293 children were vaccinated against Measles, representing 98% coverage of the targeted number of children between 6 months and 15 years of age. In November in North Darfur, covering both GoS and SLA areas, 419,991 children were vaccinated, covering 91.2% of the target population. The campaign was funded by USAID and carried out by SMoH and four international NGOs, with support of WHO and UNICEF. Following the mass vaccination campaign, the number of suspected cases reported from the Darfur states decreased (in some instances, an almost three-fold reduction was observed). Clinically diagnosed measles that had been reported between 8 and 14 May 2005 were retrospectively analysed as non-measles cases following a joint field investigation by WHO, UNICEF and the SMoH in West Darfur. World Health Organization 21

22 Meningitis The highest burden of meningococcal disease occurs in sub-saharan Africa, which is known as the Meningitis Belt, as pictured in the map on the right. During the dry season, between December and June, because of dust winds and upper respiratory tract infections due to cold nights, the local immunity is diminished increasing the risk of meningitis. At the same time, the transmission of Neisseria meningitidis is favoured by overcrowded housing at family level and by large population displacements due to crisis, pilgrimages and traditional markets at regional level. This conjunction of factors explains the large epidemics which occur during this season in the meningitis belt area. In an outbreak of meningitis, the best control measures are the early detection of cases and treatment of patients, coupled with health education. In order to respond quickly to meningitis epidemic and to prevent deaths, health facilities must have access to adequate quantities of essential supplies and vaccine. Early January 2005, 3 cases of meningococcal disease were reported from Brejing and Treijing refugee camps in northern Chad, with a population of about 60,000. The 3 cases were positive for Neisseria meningitidis W135 by latex test. Later that month, 21 suspected meningitis cases including 3 deaths were reported form Gedaref State, in the East of Sudan. The total case fatality rate was 17% (3/18). Four out of six samples were positive after Lumbar Puncture and gram stain, while two samples were positive using Pastorex. On 1 February 2005, a localized vaccination campaign was conducted in affected villages targeting 70% of the population (14,340). End January 2005, 148 suspected meningitis cases including 20 deaths were reported form Blue Nile State, also in the Eastern part of Sudan. Eighty six percent (86%) of the cases were more than 5 years old. The case fatality rate was 14%. On 1 February 2005, a localized vaccination campaign was conducted in Bakory and surrounded villages targeting 70% of the population (14,070). End 25 March 2005, 71 cases of suspected Meningococcal Meningitis including 5 deaths were reported from Darfur. Five cases from Saraf Omra, North Darfur, were laboratory confirmed by culture. Two localized meningitis vaccination campaigns were organized in Saraf Omra. One campaign was organized in the Saraf Omra administrative unit, resulting in a coverage of 81.1%, and the other campaign was organized in and around the surrounding areas of the camp (within a 20 km radius) falling partly in the state of West Darfur, resulting in a vaccination coverage of 55.60%. A total of 23,529 people were vaccinated The attack rate was cases per 100,000 population when the campaign began and three weeks after the campaign was initiated, the weekly attack rate had declined to 1.72 cases per 100,000 population. The campaign was an initiative of WHO and FMoH, and has been carried out in close collaboration with Médecins Sans Frontières Belgium and Switzerland, UNICEF, WFP and Oxfam. During the vaccination campaign, the Trivalent vaccine was used, which was the first time in Sudan The WHO Medical Emergency Response (MERT) teams vaccinated the national and international staff of UN and NGOs. By the end of April, an outbreak of meningococcal meningitis was confirmed in Abu Seroj IDP camp under Kulbus locality in West Darfur following detection of two laboratory confirmed cases (caused by Neisseria meningitides W 135). A localized vaccination campaign (with trivalent-acw135 vaccines) was carried out of the high-risk population living in and around the epicentre of the outbreak by mid May 2005, vaccinating 12,182 people. The vaccination was organized by FMoH with technical support from WHO and in close collaboration with the NGO Med Air. World Health Organization 22

23 The trend of the weekly attack rate for Meningitis in Darfur during the high risk season is shown in figure 17. After week 19, the attack rate decreased to minor levels. Figure 17. Weekly attack rate per 100,000 population of clinically diagnosed Meningitis, Darfur, 1 January- 13 May 2005 AR/100, Week To further proof the significance of vaccination campaigns in meningitis outbreaks, a projection was done for Blue Nile state. The projection shows that had the vaccination campaign not taken place, a total of 7,397 cases of meningitis could have been expected, including 592 deaths, on a population of (See Figure 18) The calculated attack rate would have been of 10% and the Case Fatality Rate of 8%. Figure 18. Meningitis outbreak projection Gessan locality, Blue Nile state 2005* cases 1, Projection (n=7397) Blue Nile (n=197) week * Projection was done using 1999 meningitis outbreak in Sudan as a model For all outbreaks, WHO provided Lumbar Puncture kits, Trans Isolate Media (TIM) for transport of cerebrospinal fluid (CSF) samples, rapid diagnostic test kits (Pastorex) and 29,000 doses of oily chloramphenicol, which is the medication of choice for Meningitis outbreaks in emergency settings. WHO developed in collaboration with FMoH, a policy guideline for detection, confirmation of Meningococcal Meningitis outbreaks in Sudan, which was disseminated widely among all health stakeholders. Workshops on micro planning for vaccination campaigns were conducted in all of the Darfur states and micro plans were established. Part of the plans is the activation of the Meningitis Task Force, the strengthening of surveillance systems, early detection and laboratory confirmation of cases, secured availability of vaccines and oily chloramphenicol as well as training for health staff and health education. The three state hospital laboratories were upgraded to diagnose and confirm meningitis cases and outbreaks by providing them with the necessary equipment, reagents and supplies for 3 months. Training for national medical staff from the Epidemiology Units of FMoH and SMoH was conducted on Meningitis outbreak investigation, response and epidemic control as well as ToT training for FMoH staff on Meningitis outbreak investigation and response and cholera detection and case management. World Health Organization 23

24 Polio In spite of tough measures to eradicate Polio, there are as of 31 December 2005, 23 confirmed Polio cases in Northern Sudan. A series of National Immunization Days (NIDs) against Polio were organized in 2005 in the whole of Sudan. Figure 19 represents the total number of children under the age of five that were vaccinated in every Polio NIDS all over the country. Figure 19: Total number of vaccinated children during Polio NIDs in Sudan in ,500,000 5,000,000 2,500,000 - Vaccinated children Jan Feb-Mar Apr May Jul Aug Sep (mop up) Nov Yellow fever outbreak in South Kordofan The Yellow Fever outbreak that affected South Kordofan in the last months of 2005 is the most important Yellow Fever outbreak reported in Sudan since the 1940 outbreak in Nuba Mountains, with 15,000 cases. As suggested by the report of the 1940 outbreak, a continuous sylvatic cycle may exist in the Nuba Mountains. The epidemic pattern suggests a major role of sylvatic Aedes sp. The number of Yellow Fever cases as a result of the outbreak has totalled 605 including 163 deaths. The Case Fatality Rate was 27.00%. The distribution of cases and deaths is shown in Figure 20. The last case was reported on 9 December The steady decrease of cases in November coincided with the end of the rainfall (no precipitations occurred in November). The Kortala community and the Shenabla nomads were the population most severely affected during this outbreak. Figure 20: Distribution of cases and deaths from 10 September to 20 December 2005 Yellow Fever outbreak, South Kordofan. No. of cases Deaths Cases CFR Vector control campaign YF vaccination campaign Week CFR% The mass vaccination campaign was rapidly implemented and as of December 18, a total of 1,473,349 people were vaccinated against Yellow Fever, representing coverage of around 91%, according to population estimates of SMoH. As per half December, there was no further transmission of the disease in South Kordofan. This and the fact there was no evidence of the presence of the vector, allow to conclude that the Yellow Fever outbreak was ended. To prevent future Yellow Fever outbreaks in South Kordofan and neighbouring states, a limited vaccination campaign is recommended to be carried out in North Kordofan, targeting El Obeid and the main administrative units (i.e. Sheilan or Bara localities) around the border with South Kordofan, before the beginning of the rainy season. World Health Organization 24

25 Crude Mortality Survey The second Crude Mortality Survey initiated in May and finalized in June 2005 was an important exercise giving evidence of the vastly improved humanitarian situation in Darfur. It provided sound scientific proof as it could be compared to the first Crude Mortality Survey conducted one year earlier, that the targeted humanitarian assistance interventions to IDPs had had a positive impact on the health situation in Darfur. After approval of the Crude Mortality Rate (CMR) Survey Protocol by FMoH, the data collection forms and survey manual were developed, pre-tested and finalized. International supervisors were selected and trained as trainers (TOT) in Khartoum on the survey methodology. They then trained the national supervisors from FMoH and SMoH in the three Darfur States. Local interviewers were recruited and trained in the conduction of interviews and completion of questionnaires. The teams consisting of international and national supervisors and local interviewers collected data for the survey from the 270 selected clusters in Greater Darfur. Per State 90 clusters had to be completed, 30 from IDPs living in camps, 30 from IDPs living in settlements, outside of camps, and 30 from affected communities. The data were entered in a specifically for this mortality survey developed screen from the epidemiological software Epi Info. After data entry and analysis, the crude mortality rate was calculated to be 0.8 deaths per 10,000 people per day in Darfur. This figure is below the threshold of one death per 10,000 people per day, as is common in humanitarian crises and shows a large reduction compared with the crude mortality rate of 1.5 deaths per 10,000 people per day in North Darfur, and 2.9 in West Darfur from the first mortality survey. The results of the Mortality Survey 2005 clearly demonstrate that international humanitarian assistance has made a dramatic impact in Darfur. However, the humanitarian situation remains fragile. The study s recommendations highlighted that: Existing humanitarian interventions should be intensified to reduce overall mortality; The early warning system needs to be enhanced for prospective mortality surveillance. Additional efforts are needed to improve the environmental sanitation (access to clean water and latrines); Upgrading of laboratories The upgrading of 60% of the public health laboratories in Darfur improved the detection and response to outbreaks. The National Public Health Laboratory (NPHL) in Khartoum was provided with reagents, supplies, and equipment as well as trans-isolate media and rapid diagnostic testing for Meningitis. In the NPHL, a serology department for Hepatitis E ELISA testing was established, as well as a specimen referral system through the national courier company CASSI Express. Training on sampling technique and specimen referral was conducted in the three Darfur states, as well as Training of Trainers for NPHL staff members for advanced ELISA testing technique. The WHO Sudan database on tracking of laboratory samples shows that until May-June 2005, the average time required between sending samples from Darfur to the in Khartoum and receiving the results was 11.7 days, including the travel time. In July- August 2005, this time period had been reduced to 4.5 days (also including travel time from Darfur to Khartoum). The Eastern and Southern part of Sudan has been added to the specimen-referral system of the NPHL. World Health Organization 25

26 b. Way forward for 2006 The focus will be on improving the quality of the EWARS through close monitoring of reporting units and the increase in both number and frequency of existing and newly identified reporting units. Another priority is the linkage between the epidemiological surveillance of water-borne and vector-borne diseases such as Hepatitis E, Bloody Diarrhoea, Meningitis, Malaria, and others with statistics of water purification and vector control measures taken. The significance of the existing relation between the appropriate measures taken and the incidence in disease, is further proof for the effectiveness of the work. Continuous coordination with other health partners remains a priority, as well as capacity building at FMoH, SMoH and at health facilities level. Training on the improvement of the surveillance system at camp level needs is planned. The upgrading of the laboratory capabilities at national and state levels after the physical rehabilitation of the state hospital laboratories is an ongoing process. Although specimens from suspected cases of the diseases under surveillance have been routinely collected and sent through a courier to the NPHL in Khartoum, the system of samples transmission and laboratory feed back needs to be fine-tuned in order to avoid delays in receiving results. Although the Weekly Morbidity and Mortality Bulletin is already an excellent means to provide a broad audience with updates information on disease patterns in Darfur, for improvement of the quality, SMoH staff needs to be further trained on rapid assessment and investigation of disease outbreak. Also, standard guidelines for rapid assessment/investigation of disease outbreaks need to be disseminated in Arabic. World Health Organization 26

27 4. Access to Primary Health Care, and Environmental Health WHO s role in Primary Health Care, Reproductive Health and Environmental Health focuses on the technical expertise to support other agencies. Both Primary Health Care (PHC) and Environmental Health are the mandate of UNICEF. Reproductive Health, an important aspect of Primary Health Care, is the responsibility of UNFPA. Related to PHC, the quality control of PHC clinics has become WHO s main objective. As this is part of the coordinating role WHO has within the health sector, this specific programme area was already described in chapter 1. Other objectives area the increase of accessibility to PHC services such as TB DOTS, VCT centres for HIV/AIDS and Expanded Programme of Immunization (EPI). In Reproductive Health, the implementation of the Integrated Management of Childhood Illness (IMCI) programme is the most important objective. The environmental health programme aims to reduce environment-related disease and death among the population. The main aspects of the programme are water supply, excreta disposal, solid waste management, and vector control. In Darfur and Kassala, the programme focuses on practices in camps and settlements. In Kadugli, the programme mainly focuses on capacity building of local state governments. Health promotion is an overall environmental health activity Improve the environmental conditions in hospitals serving IDP populations through assisting in the upgrade of water supply and excreta disposal facilities and the establishment of sound solid waste management practices; a. Achievements Expand access to primary health care services At the end of 2005, 184 fixed health centres and 36 mobile centres were providing PHC in Darfur, representing coverage of 57% of the total conflict affected population. As the accessibility of the population in Darfur has decreased due to the increased insecurity, the coverage of PHC, water and sanitation, clean water and basic drugs supply has decreased significantly, when comparing the months of January, July and November 2005 vii. (See Figure 21) Figure 21: Percentage of coverage and accessibility of the total conflict affected population 100% PHC sanitation accessibility clean water basic drugs supply 75% 50% 25% Jan Jul Nov As NGOs are working on a temporary basis, the number and location of health centres is variable. For example, between May to August 2005, 14 new PHC centres were opened and 9 new Partnership and Cooperation Agreements (PCA) were signed with different NGOs. vii Darfur Humanitarian Profile No January 2005, No July 2005 and No November World Health Organization 27

28 Immunization The indicator for adequate EPI coverage is the availability at primary health care facilities of the Diphtheria- Pertussis-Tetanus (DPT3) vaccine with an average of 61%. To enhance routine immunization services in Greater Darfur, cold chain items were distributed, resulting in an EPI vaccine availability of 50%. 60% of pregnant women received two doses of Tetanus Toxoid (TT) vaccine at primary health care facilities, reaching an average coverage of DPT3 of 61%. The coverage rate of the two doses of Tetanus Toxoid (TT2) vaccine is still around 20% due to weak social mobilization and low social awareness. HIV/AIDS At least 500 clients have benefited from Voluntary Counselling and Testing (VCT) for HIV/AIDS services. VCT Centres have been identified in all of the Darfur states and rehabilitation started in September The blood bank at El Fasher Teaching Hospital has been rehabilitated. In West and North Darfur 400 blood transfusion bags and 800 blood transfusion sets were distributed. A two-weeks training for providers of Voluntary VCT for HIV/AIDS was conducted in Kassala for social workers, midwives and medical assistants of the main health facilities in Kassala. WHO organized two assessments missions in Malakal and Wau for the establishment of VCT centres. Provision of Post Exposure Prophylaxis (PEP) antiretroviral treatment as part of GBV care in IDP camp settings in Darfur is challenging. While some partners have reported providing PEP, the local sensitivities have hindered the open sharing of their experience thus far, yet this experience in needed to better inform the adaptation of the draft PEP guidelines to realities on the ground. A one-day training was conducted on the National Guidelines on HIV/AIDS Post Exposure Prophylaxis (PEP) for Survivors of Sexual Assaults for medical students of El Fasher University by SMoH with the support from UNFPA and WHO. During a 4-day workshop 18 medical assistants were trained in Sexually Transmitted Infections (STIs) case management using syndromic approach. The training was organized by SMoH, WHO and UNFPA and funded by the Sudan National AIDS Programme (SNAP). SNAP finalized and endorsed of the national PEP protocol, with support from WHO and UNFPA. In South Darfur HIV/AIDS awareness raising sessions were conducted for youth and community volunteer IDP groups, 600 police staff, and Training of Trainers was conducted for peer educators. In West Darfur, training on HIV/AIDS behaviour communication change was conducted for 29 media persons. Reproductive health A series of joint reproductive health assessments was conducted in the three Darfur states. Results revealed low minimum standards in reproductive health. A special task force was formed to reinforce health facilities in the identified weak areas. The distribution of Reproductive Health kits covering 3 million people were supplied to 22 NGOs operating in both GOS and non GOS controlled areas. This has led to the enhancement of access to reproductive health care in the three Darfur states. Almost 500 midwifery kits were provided. A total of 137,191 Long Lasting Insecticide Treated Nets were provided to pregnant women and children, representing 28.7% of the total need. Clean delivery rooms were equipped in IDP camps with a population of more than 60,000. Clinical delivery kits and 2,000 individual clean delivery packets were distributed. Basic health kits, New Emergency Health Kits, parachecks and other material is handed over on a regular basis to PHC units in IDP camps. A total of 400 PHC kits were distributed to the health centres, as well as 90 various emergency reproductive health kits including 2,000 individual clean delivery packets, 600 rape treatment packets. A total of 15,475 individual family planning commodities and drugs were distributed. Different treatment protocols were distributed to health partners. World Health Organization 28

29 The WHO guidelines on Clinical Management of Rape Survivors has been adapted to the Darfur reality. The Gender Based Violence (GBV) Task Force, under the lead of UNHCR and UNFPA and composed by different partners, selected five IDP camps to reinforce protection of women in the camps as well as confidentiality in post-rape cases. In June and July 2005 a large number of midwives, medical doctors, and medical assistants were trained on clinical management of rape survivors all over Darfur. The training module used was the revised edition of the WHO Guidelines on Clinical Management of Rape Survivors. Rape treatment kits were distributed for 600 rape survivors. Also, 61 nurses and midwives and 20 Community Health Workers working in IDP camps were trained in counselling of victims of GBV and patients infected with HIV/AIDS. The workshops were facilitated by UNFPA with support of WHO and SMoH. Integrated Management of Childhood Illness (IMCI) Campbased health services face a demand that mainly originates from the under-five age group. The EWARS system for Darfur reports that 39% to 45% of the total consultations belong to this group. The main causes are Acute Respiratory Infection, Diarrhoeal Diseases, Malaria, Malnutrition and Measles. The situation calls for a comprehensive child health care intervention that addresses the sick child as a whole as well as the key family practices that prevent child illness. A series of Training of Trainers workshops as well as crash training workshops on IMCI Standard Case Management for health personnel in the IDP camps were conducted all over Greater Darfur from March to May In every State, two five-day crash workshops were organized for over 100 medical assistants and 35 Medical Doctors working for SMoH and NGOs. The training program focused on the improvement of diagnosis and management skills to take more effectively care of children in their health facilities and was facilitated by FMoH and SMoH and technically and financially supported by WHO. A total of 60 health facilities are currently working with the IMCI strategy. Staff from FMoH travelled to the Greater Darfur to follow up on the previously trained Medical Doctors regarding the implementation of the IMCI strategy in health facilities in IDPs camps. It was found that in the majority of the health facilities the strategy is properly implemented. An IMCI Knowledge Attitudes and Practice (KAP) survey was carried out in several IDP camps, amongst them Kalma camp in March 2005, with a total population of 23,000. The KAP survey aims on child care family practices. The exercise was a joint effort between WHO, the PHC department of SMoH and the NGO IRC. An IMCI core group was set up within SMoH in April 2005, consisting of one IMCI coordinator, one paediatrician and one inspector for PHC facilities. Training on the management of severe malnutrition was carried out for medical assistants and nutritional assistants in Darfur. The training was organized between WHO, SMoH and UNICEF. Environmental Health response to Floods in Darfur In August 2005, Abu Shoak and As Salaam IDP camps in North Darfur were flooded and an estimated 800 houses and 500 latrines were destroyed. In El Fasher Town, the drinking water distribution system was damaged, the Maternity Hospital was flooded, and 800 households were damaged. In West Darfur, an additional 200 shelters and approximately 900 latrines collapsed in Ardamata IDP camp. WHO supported SMoH, the Sudanese Red Crescent and other NGOs working in the flood-affected camps with the chlorination of water sources by providing the necessary reagents and chlorine. WHO also mobilized microbiological testing kits for continuous monitoring of the drinking water quality. World Health Organization 29

30 WHO and SMoH supported the flooded Maternity hospital in El Fasher Town with pumping the water out of the wards and compound and by building a fence of sand bags to prevent the hospital from future flooding. WHO provided 75 drums of water to ensure sufficient water supply after the destruction of the city water pipe. A program of community sensitization on diarrhoea disease risk was launched by the SMoH with support from UNICEF and WHO. 250 community health workers conducted a door-to-door sensitization campaign for five days in El Fasher Town, reaching 25,000 persons with messages on individual hygiene, chlorination of water and the importance of draining stagnant water: the preferred breeding places of Malaria mosquitoes. Vector control spraying campaigns were boosted in the floodaffected IDP camps. WHO has provided emergency drugs in response to flooding in Damazin, Blue Nile State Water Quality A series of workshops on Water Quality Surveillance and Monitoring were held in all of the Darfur States for participants of the Ministry of Health and the Water and Environmental Sanitation Department (WES) in The workshops were conducted in partnership with NGOs Oxfam and IRC. Seventeen representatives from FMoH, SMoH, WES, WHO and UNICEF of the three Darfur States were trained in Water Quality Surveillance and Monitoring during a one-day workshop in Khartoum. WHO and UNICEF also conducted a two-day training session on the use of water quality test equipment for 15 participants of the same organizations. SMoH and WES representatives from across the Darfur region attended training courses on Water Quality Surveillance and Monitoring and on the use of water testing equipment in El Fasher in March and June Course topics included reviewing basic water quality principles, hands-on use of equipment in the classroom and the field, and practice in conducting a sanitary inspection. The course also focused on preparing 1% chlorine solution, determining chlorine demand, and measuring chlorine residual. Guidelines and protocols were distributed and every participant was given a comparator for measuring free chlorine residual. Camp Health Coordinators of IDP camps in Darfur were trained in the use of Environmental Health services such as drinking water quality, sanitation, solid waste management, and control of disease vectors (mosquitoes, flies, rats, etc.) for the prevention and control of the spread of diseases by optimizing. In Kalma and Ottash IDP camps in South Darfur, almost 100 community health workers were trained on water-related diseases with the emphasis on acute jaundice syndrome. Water testing kits were distributed in the Darfur states in April The kits were handed over to the SMoH with the agreement that they would be made available to WES, the NGO community, and others as needed. In addition, testers for free chlorine residual (pool testers) were provided to the SMoH. The continuous monitoring of the quality of drinking water in IDP camps and Al Fasher in North Darfur is implemented by WHO and SMoH. WHO continues to support the African Union in North Darfur, in maintaining the quality of their water supply for domestic use in their camps by providing technical assistance and equipment. Environmental Health staff from WHO continues to provide technical support to the water and sanitation group of Kalma IDP camp, South Darfur, to solve problems associated with the low chlorine levels in the bladders and at household level. An evaluation form for water storage and handling practice in homes was designed and provided to partners in English and Arabic. Several sanitary inspection visits were carried out in IDP camps in Darfur. WHO provided technical advise to improve the quality of the water resources and to decrease the risk for contamination. WHO also provided the Camp Health Coordinators of the visited camps with Aqua tabs for the chlorination of open dug wells. World Health Organization 30

31 Vector control In February 2005, an international vector control specialist was recruited. Assessments of the vector control situation in camps and settlements in the three Darfur states were followed rapidly by an extensive training and spraying programme in the most vulnerable IDP camps. A housefly assessment for vector control was done in Habila in March Hygiene promoters were trained on housefly biology (lifecycle and breeding sites), behaviour and on how to monitor their population densities. Several workshops organized by WHO, focused on informing and familiarizing technical staff with new developments in vector control interventions, strengthening participants knowledge in vector control during emergency situations, and allowing participants to share information, knowledge, and experiences from different states. Vector control training for SMoH and WES staff was carried out in Darfur and Kassala. 91 spray operators, mixers, enumerators and supervisors from El Gash, Kassala, Atbara and Seetit localities in Kassala State were trained in new approaches in malaria vector control in a workshop organized jointly by the state malaria control programme and WHO in Kassala town. A four-day refresher training for 40 laboratory technicians was conducted on Malaria Laboratory Technique and Survey. All over Darfur, WHO is supporting SMoH in the planning and implementation of spraying campaigns and other vector control activities in IDP camps for the prevention of Malaria. A global work plan for Greater Darfur was drafted in April 2005 to enhance coordination of vector control with relevant NGOs and SMoH for a more effective implementation, monitoring and evaluation of vector control activities by improving the selection of appropriate vector control interventions for the three states. Training of vector control staff and operational research for appropriate implementation of vector control activities is included. Hand pumps and insecticides were supplied to the NGO SC-US to conduct vector control campaigns in Gemeiza and Fur Baranga areas in West Darfur. As a collaborative effort between all health partners, several vector control campaigns were organized in IDP camps in Darfur. WHO donated equipment (motorized sprayer pumps, hand sprayer pumps and protective cloths) and insecticide (Abate, Ancothrin and Deltamethrin 2.5% WP) to SMoH and carried out training of sprayers. A proper monitoring tool of ongoing vector control activities in the camp was put in place. WHO donated Deltamithrene and Hudson sprayers to the NGO SC-US to carry out spraying campaigns against mosquitoes in Habilla, West Darfur. Also in West Darfur, WHO is supporting the NGO Norwegian Church Aid (NCA) in vector control activities in Hamsadagig, Hamadiya and Hasa Hisa IDP camp, specifically with larviciding, Indoor Residual Spraying and impregnating of bed nets as part of the Roll Back Malaria program. In North Darfur, WHO, UNICEF and the SMoH are supporting the Spanish Red Cross with eradication of mosquito larval breeding places in the IDPs camps around El Fasher. The spraying of houseflies breeding and resting sites in Kalma camp (with an estimated population of 140,000), South Darfur, and Kassab camp (with an estimated population of 14,500), North Darfur, was carried out in April It is hoped to drastically reduce the population of houseflies. The spraying activities were implemented by the SMoH with support from WHO, UNICEF, CARE and other partners. The WHO test kit was used to determine the susceptibility status of both houseflies and blow flies (the green/blue flies) to deltamethrine, the insecticide in use. Sixty-four spray operators (spray persons, mixers, enumerators and supervisors) received a two day s training in Kalma camp, South Darfur, on spraying techniques, proper maintenance of hand spray pumps and on monitoring process. World Health Organization 31

32 To control houseflies, filth flies and mosquitoes, a second round of spraying with deltamethrin inside human dwellings, shops, restaurants, animal shade, garbage and latrines was conducted in Kalma IDP camp, South Darfur. A seven day-spraying campaign in Abu Shoak and Salaam IDP camps, North Darfur was carried out by SMoH and WHO. A housefly spraying campaign was conducted in Durdi IDP camp, South Darfur by WES. Aquatic stage vector control activities are ongoing in Kalma IDP camp, South Darfur, in collaboration with OXFAM and WHO. Malaria campaigns have also been carried out in Kassala, Elgash, River Atbara and Seteet localities. WHO and SMoH implemented a survey into the presence of a parasite that is not usually found in Sudan among army troops returning from Eritrea. Spraying of the military camp is done to avoid spread of a new type of Plasmodium. A vector control campaign against Aedes Aegypti mosquitoes was done in Port Sudan. WHO donated 3000 Kg of Deltamethrine for Malaria spraying to the Kassala SMoH. Also, 100 medical assistants were trained on dengue fever and Malaria in Port Sudan. WHO also provided Deltamethrine for spraying activities in Zam-Zam camp, North Darfur. Solid waste Several clean-up campaigns were carried out in Darfur, amongst others in Ardamata IDP camp in West Darfur, by hygiene promoters of the Water and Environmental Sanitation Department (WES). A total of 105 latrines were built in a new location for IDPs near Ardamata in West Darfur, by MEDAIR and WES. WHO provided technical support and donated an assortment of tools and equipment to the NGO EMDH for a clean-up campaign in Abu Shoak IDP camp, North Darfur. WHO and SMoH carried out a cleaning up campaign in Nyala Teaching Hospital, South Darfur, to minimize the accumulation of solid waste. The cleaning-up campaign for El Geneina town and surrounding IDP camps was done in two phases. The NGO Medair coordinated the initiative, in close collaboration with SMoH, WHO, UNICEF, other NGOs and the locality. The landfill that was constructed by WHO in El Geneina was enhanced for more effective and efficient solid waste disposal. Hygiene promotion A Health and Hygiene Promotion campaign has been conducted during six days in Abu Shoak camp, including the new arrivals area, in April WHO along with SMoH, IRC, ACF and OXFAM conducted a three day training workshop on rapid response health promotion campaign to Community Health Workers. More than 210 Community Health Promoters reached and sensitised 87% of the population on prioritizing early referral to clinics, hygiene promotion and oral rehydration therapy at the household level. b. Way forward for 2006 By ensuring the functional rehabilitation of local health infrastructure, it is hoped displaced persons will be encouraged to return to their homes. In the improvement of comprehensive PHC services, the focus will remain on child and maternal health care. One of the main issues to be strengthened is management at IDP camp level. WHO is following up on the recommendations made during sanitary surveys conducted in Ardamata, El Riyad, Kerenick, and Saraf Jidad IDP camps and is working on the establishment of an operational outbreak tracking tool at State level in Darfur. WHO is also supporting WES and SMoH in the strengthening the water testing capacities of existing laboratories. In case of emergency, and is ensuring that a sufficient amount of chlorine supplies is available for Darfur. For food safety purposes, WHO is looking into supporting the Veterinary Department of the State Ministry of Health (SMoH) in establishing a slaughterhouse in El Geneina. World Health Organization 32

33 World Health Organization 33

34 5. Programme Management A large share of the financial requirements represents staff time that has been dedicated to activities (assessments, meetings, planning) that carry little or no additional costs, but for office and travel expenditures; while per diem rates in Darfur are low, they are quite high in Khartoum and they carry some weight to the costs of international staff. Another important share of the budget has gone to the purchase of drugs and medical supplies. Security concerns impose a strong investment in MOSS-compliant vehicles and need for security officers. Overhead costs for monitoring, reporting and evaluation took up 10% of the budget. Of these, 5% will cover costs incurred at regional level and 5% at Headquarters level, as a fair reflection of the difficulty of providing strategic and technical backstopping to a humanitarian programme in a context as complex as today s Sudan. The cost of satellite communications, that were set up in an early stage by WHO, were shared with other UN agencies and NGOs. In the sub offices, NGOs and other UN agencies without own satellite connection, are being offered this service through WHO. The WHO Sudan team has been strengthened with one international Health Information Systems specialist, one international Nutrition expert, one GIS-expert. World Health Organization 34

35 III. Conclusion WHO was well perceived by partner agencies. WHO's increased presence on the ground was noticeable and showed commitment, value and technical expertise. One of the success stories of 2004 was the development of the Early Warning and Response Surveillance (EWARS) system, through which WHO played a large role in averting disease outbreaks. Disease control and surveillance activities were timely and WHO's involvement in vaccination campaigns allowed a good coverage. WHO was effective in getting people on the ground. One participant described WHO as one of the more effective UN agencies because they geared up, got stuff cleared and moved and got more people out there. In general, WHO has developed good working relationships with NGOs, other UN organizations and national authorities and continues to maintain them. The majority of health partners have observed that WHO s contribution to the emergency health action in Darfur was significant. WHO is recognised for its leadership role and its comparative advantage in health sector coordination and technical expertise. Setting up early the warning and surveillance systems and the application systems for the waiving of user fees for affected population in secondary health facilities are only two examples. WHO is used as a reference point for early detection and rapid response to emerging health threats and epidemics. The joint evaluation has validated and confirmed that WHO is on the right track. viii The prospect for Sudan is cautiously hopeful: the peace agreement between the Government of Sudan and the Sudan People's Liberation Movement/Army was signed on 9 January The country s immediate future now depends on the commitment of its leaders to maintain peace. The response of WHO and the United Nations in 2005 will be focused on reinforcing the peace process and on responding to the needs of some four million people ix. The peace agreement gives much reason to be optimistic for the resolution of the crisis in the Greater Darfur. Still, attacks are continuing, and as long as people are unable to go back to their villages, the humanitarian response will remain necessary. The return of internally displaced populations to their villages needs to be well-planned, especially to destroyed villages where health facilities are absent. International community attention is still high on Darfur, with health being one of the main topics. WHO will amend and reorient activities as the context evolves towards a more stable phase and a transition to peace. For WHO, the challenge now will be to keep up the effort and improve on the quality, the timely delivery and the coverage of different services and tasks provided. The moral and financial support from donors and partners and cooperation with the health authorities will be essential to consolidate these results. x Way forward The prospect for 2006 is hopeful.the country s immediate future now depends on the commitment of its leaders to maintain peace. The response of WHO and the United Nations in 2005 will be focused on reinforcing the peace process and on responding to the needs of some four million people xi. The peace agreement gives much reason to be optimistic for the resolution of the crisis in the Greater Darfur. Still, attacks are continuing, and as long as people are unable to go back to their villages, the humanitarian response will remain necessary. The return of internally displaced populations to their villages needs to be well-planned, especially to destroyed villages where health facilities are absent. International community attention is still high on Darfur, with health being one of the main topics. WHO will amend and reorient activities as the context evolves towards a more stable phase and a viii ECHO/WHO Joint evaluation on the WHO Darfur operations in the context of the Health Action in Crises Three Years Programme (TYP), held from 22 February to 2 March 2005 ix 2005 United Nations and Partners: Work Plan for the Sudan x ECHO/WHO Joint evaluation on the WHO Darfur operations in the context of the Health Action in Crises Three Years Programme (TYP), held from 22 February to 2 March 2005 xi 2005 United Nations and Partners: Work Plan for the Sudan World Health Organization 35

36 transition to peace. For WHO, the challenge now will be to keep up the effort and improve on the quality, the timely delivery and the coverage of different services and tasks provided. The moral and financial support from donors and partners and cooperation with the health authorities will be essential to consolidate these results. xii xii ECHO/WHO Joint evaluation on the WHO Darfur operations in the context of the Health Action in Crises Three Years Programme (TYP), held from 22 February to 2 March 2005 World Health Organization 36

37 IV. Annexes World Health Organization 37

38 Annex 1: WHO Sudan Proposed staff partners World Health Organization 38