UNITED NATIONS DEVELOPMENT PROGRAMME

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Acronyms

AIDS ACSM Acquired Immunodeficiency Syndrome Advocacy Communication & Social Mobilization ART Anti Retroviral Therapy BCC Behavioural Change Communication CBO Community‐Based Organization CBS Central Bureau of Statistics CMS Central Medical Store CCM Country Coordination Mechanism CSM Condom Social Marketing CSOs DOTs Civil Society Organizations Direct Observatory Treatment FSWs Female Sex Workers GFATM/GF The Global Fund to fight AIDS, Tuberculosis and Malaria/Global Fund HBV Hepatitis B Virus HCP Health Care Provider HCV Hepatitis C Virus HIV HSS Human Immunodeficiency Virus HSS Health Systems Strengthening Health System Strengthening IDPs Internally Displaced Persons IMAI Integrated Management of Adolescent and Adult Illness LFA Local Fund Agency LLIN Long Lasting Insecticidal Nets MARPs Most At Risk Populations M&E MDR Monitoring and Evaluation Multiple Drug Resistance NMCP National Malaria Control Programme NGO Non Governmental Organization NTP National Tuberculosis Control Programme OI Opportunistic Infections PITC Provider‐Initiated HIV Testing and Counselling PLHIV People Living with HIV PMTCT Prevention of Mother To Child Transmission PR Principal Recipient

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PSM Procurement and Supply System RH Reproductive Health SFPA Sudan Family Planning Association SGP Safe Guard Policy SGS Second Generation Surveillance SNAP Sudan National AIDS Control Programme SOP Standard Operations procedures SR Sub‐Recipient SRCS Sudanese Red Crescent Society SSF Single Stream Fund STIs Sexually Transmitted Infections TBMUs Tuberculosis Management Units UNDP United Nations Development Programme UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund VCCT Voluntary Confidential Counselling and Testing VNRBDs Voluntary Non‐Remunerated Blood Donors WHO World Health Organization

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EXECUTIVE SUMMARY

This Report provides an overview of Global Fund financed activities implemented in 2012 in Sudan in collaboration with partners and The Principal Recipient, UNDP. The Report will highlight the general objectives of all active Grants throughout 2012, the main achievements; as well as the main challenges faced. The report will also outline both short and longer term interventions that will be implemented in 2013 and beyond.

Some of the major achievements in 2012 that are highlighted in this report are the following:

During the year, malaria project activities have enabled 2,894,862 cases of uncomplicated and severe malaria cases to receive anti‐malarial treatment according to National standards and guidelines. Through the malaria grant, a total of 3,106,115 bed nets were distributed protecting an approximately 6.2 million people from getting malaria. 2,229 dispensaries in rural and hard‐to‐reach parts of the country were fully supported to continue providing free Rapid Diagnostic Test for malaria; while the project has continued supporting the provision of free anti malarial drugs for 4,330 health facilities throughout Sudan.

Through Behaviour Change Communication (BCC) interventions; HIV/AIDs grants reached over 168,000 people, almost 137,335 members of Most‐At‐Risk & vulnerable population (youth in IDPs) as well as 4,000 young people from out‐of‐school settings. The HIV/AIDS grant reached 4,487 MARPs (MSM&FSW) through a peer education approach. Counselling and testing services were also provided to 60,036 people including pregnant women and MARPs.

More than 85,000 people have received HIV testing and counseling services; reaching 5,500 people with advanced HIV infection to receive ARV combination therapy. During the year, 2,574 people were retained on ARV treatment. A total of 2,032 TB patients have begun ARV treatment during or at the end of their TB treatment. 79 pregnant women have also received ARV treatment as part of the overall intervention to reduce the risk of mother to child transmission of HIV. In 2012, sseveral capacity development interventions were held to PLHIV associations, other CSOs and SNAP. About 151 health care providers were trained on syndromic management of STIs according to the national guideline, while 59 health care providers received training on Infection prevention in health care settings.

With regard to Tuberculosis project, the grant has enabled the detection of 6,518 new smear positive TB cases; with 70.6% of new smear positive cases being successfully treated. In 2012, a concerted effort was made that enabled the detection and treatment of 254 MDR TB cases. As part of TB/HIV collaborative activity a total of 190,589 condoms were distributed to TB patients. A total of 2, 827 people were trained on TB management, contact tracing and management, PPM, DOTS links and

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health communication skills in 2012. In an effort to expand TB services in Darfur states, 27 TBMUs & 54 DOTs were newly established during the year.

As part of the cross‐cutting health system strengthening effort, site assessment and design work for rehabilitation of the Academies of health Sciences was finalized and rehabilitation and construction initiated. 14 Academies of Health Sciences in 14 states were provided with minibuses to facilitate their daily work and commute students to and from their practice health facilities and the Academies. Equipment to upgrade 5 rural hospitals, 25 health centers, 15 laboratories & 5 Academies were procured & handed over to MOH. A total of 293 health management personnel from 114 localities were trained in decision‐making, teamwork, effective meetings, and health planning and district health management. The capacity of Locality Health Management Teams is enhanced by the provision of vehicles, office equipments and computers. 25 personnel from States and Federal level were trained on M&E of the health system. 42 health managers from states and localities were also trained in health economics/financing. 5 fellowships in health economics & health care management were awarded in collaboration with the National Health Insurance Fund & the University of Chulalongkorn, Bangkok, Thailand. 20 health managers from states & localities were enrolled in health economics/financing in‐country for a medium term course.

At the end of the report, main challenges and future plans are listed. Several annexes are also provided showing details of performances for specific indicators related to the respective projects. AS can be seen from this report, it is clear that within the various challenges faced, the UNDP/ GFATM projects did manage to reach and achieve the majority of the targets it had set from the beginning and will continue to deliver more with a aim of saving lives, enhancing better health and strengthening the health system to sustainably mitigate the impacts of the three diseases.

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Sudan Map

Health Service Provision points supported by UNDP/ GFATM for the three diseases throughout the country: (Needed here)

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BACKGROUND AND INTRODUCTION

With an annual growth rate of 2.8%, the total population of Sudan as projected from 2008 census is equal to 34.1 million for 2012, 88% are settled, including 32.7% in urban areas, while 8% are nomads. Almost 6.9% of the population is internally displaced. There has been increasing urbanization, with natural disasters, civil conflicts and poor conditions in rural areas, contributing to this.

Sudan comprises 17 States each divided into localities, which in total are 1841 _{but varies with time due to}

redrawing of the boundaries of the existing ones.

The epidemiological profile of Sudan is typical of other Sub‐Saharan African Countries, dominated by malnutrition and communicable diseases, frequently aggravated by natural disasters (floods, heavy rains and droughts) as well as sustained internal conflicts. The main causes of morbidity and mortality are infectious and parasitic diseases, particularly malaria, tuberculosis, schistosomiasis, diarrheal diseases, acute respiratory infections and protein‐energy malnutrition.

With changes in socio‐economic and lifestyle conditions, non communicable diseases (NCDs) are now emerging as a public health problem in Sudan. Hypertension, diabetes, heart disease, cancer, asthma, cataract and mental disorders are the major ones prioritized in the 2011‐2016 National Health Sector Strategy.

Sudan made progresses towards the Millennium Development Goals (MDGs) with a reduction in child mortality by a third between 1990 and 2010, and reduction in the maternal mortality rate by 60%. However recent trends suggest that Sudan is unlikely to reach the MDG targets for child and maternal health by 2015. Another feature is the marked disparity between states in health status, for example, the infant mortality rate is 60 overall but ranges from 39 per 1,000 in Gezira state to 85 per 1,000 in Red Sea state2. The range is even wider for maternal mortality rates, ranging from 106 per 100,000 in Northern to 335 per 100,000 in South Darfur. These indicators demonstrate considerable inequity in health status across the country.

The health service delivery system in Sudan includes a range of public providers and both not for profit and for profit private sector providers. The National (Federal) Ministry of Health (FMOH) has a leading role in policy and stewardship while responsibility for delivery of public services is largely led by states and their localities and by other agencies including police and army health services and the National Health Insurance Fund (NHIF). In areas affected by conflict, Non‐Governmental Organization (NGOs) have been playing a substantial role in service delivery. This has resulted in an uncoordinated patchwork of services, with gaps in

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FMOH. Mapping of PHC services in Sudan 2010

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some states and duplication in others. The high proportion of public funding and qualified health workers allocated to public hospitals and substantial costs of administration leaves less than 20% of public funds allocated to primary health care (PHC) services and public health programmes.

PHC services include community level, small family health units, larger family health centres and rural/locality hospitals, which report to the locality administration. Public health services (environmental, food safety, campaigns) are managed from the locality level as well. The distribution of PHC facilities is uneven across the country. The ratio of PHC facilities to population varies from 1:3,000 people in the Northern State to 1:21,000 people in South Darfur, compared to the planned 1:5,000 population. In six states over 20% of the population lives more than 5 km from a health facility (HF) (five Darfur states and Red Sea). PHC services are variable, with only 24% of facilities offering services in all the main components of the PHC package (reproductive health, immunization, nutrition, prevention and treatment of common diseases and essential drugs).

Analysis of health system financing indicates that 65% of funding is from private sources, almost all out of pocket expenditure. Reliance on out of pocket spending for health care exposes individuals to financial risk and is likely to reduce access for the poor. Public funding has risen considerably in recent years and reached 9.8% of public expenditure in 2011. The allocation of public funding is very uneven across states once population is taken into account, ranging from below 10 SDG per person in South Darfur to almost 40 SDG per person in Red Sea state in 2008. The NHIF and other health insurance schemes (mainly for public sector staff) fund some 7% of all health spending while coverage of health insurance is around 37% of the population; this indicates that NHIF is only providing limited cover for the costs of health care. In addition payments are on a fee for service basis which does not encourage efficiency and cost control.

Health information in Sudan is primarily based on health facility reporting supplemented by surveys. The MOH hospitals generally report regularly but there are gaps in reporting from PHC facilities in many states and low coverage of other sectors including private providers. There are multiple systems and forms for data collection for different programmes. Data quality assurance is limited and systems for data management and analysis are largely manual. Annual statistical reports are produced at national and state levels but there is limited use of data at sub‐national levels. Human Resources for Health (HRH) are a critical component of service delivery. Issues facing Sudan include the relatively high number of medical doctors relative to nurses, midwives and paramedics, and the tendency of doctors to emigrate for better conditions or to work in urban areas and referral hospitals, leaving PHC and rural hospitals understaffed. States have established Academies of Health Sciences to redress this imbalance in the skill mix and further efforts are required to improve the distribution of health workers and to maintain their professional development. Community midwives have played an important role in Sudan in reaching

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remote populations and more recently programmes have established specialized community workers such as for malaria.

Basic equipment and services are not available in a significant proportion of health facilities especially in poorer rural states. Medicines are a major share of the health expenditure by individuals (some 40%) and use of antibiotics is very high, at over 70% of prescribed medicines, which suggests serious over‐use of these medicines. There is a single supply agency for the public sector but in practice there are multiple procurement and supply arrangements, including more than 15 different systems in the Federal MOH linked to different programmes.

To help the country join the global fight against HIV/AIDS, TB and malaria, UNDP’s role is two‐fold: it manages all funds allocated by the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria (GFATM) in Sudan; as well as implementing interventions that address these diseases as they affect development, governance, the protection of human rights and gender equality.

Since 2005, the Country Coordinating Mechanism (CCM) in Sudan3_{nominated UNDP as the Principal Recipient}

(PR) for the implementation of the GFATM supported grants4. As the Principal Recipient for 8 grants (2005‐ 2016) amounting to more than USD 400 million, UNDP is managing the largest fund portfolio in the Middle East and North Africa Region. UNDP‘s management role consists of implementing grants, ensuring financial accountability, and training of a variety of national and international counterparts on programme management and financial accountability. The established GFATM Programme Management Unit, which falls within UNDP’s MDG and Poverty Reduction Unit, is responsible for the programmatic and financial management of the grants, the procurement of HIV/AIDS, malaria and TB‐related commodities and capacity development of the national partners: Sudan National AIDS Programme (SNAP), National Malaria Control Programme (NMCP), National TB Programme (NTP), Directorate General of International Health and Planning (DGIHP) and national NGOs. To ensure the proper management and execution of grants, the Global Fund Programme Management Unit is organized into eight sections‐ four managing the specific grants, a Monitoring and Evaluation, Finance, Procurement and Supply Chain Management sections.

3

There were two CCMs overseeing GF grants implementation in North and South Sudan before the cessation of the South. 4_{SUD-305-GO4-H, SUD-506-G08-H, SUD-506-G07-T, SUD-202-G03-M, SUD-708-G10-M, SUD-T-UNDP}

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Table 1: Overview of GFATM grants in Sudan since 2005

Grant Name Project Title Grant Period Budget in USD

Round 2 Malaria Malaria Prevention and Control Apr 1

St_2005‐

Sep 30th 2009 33,240,453 Round 3 HIV/AIDS Sudan Proposal for fighting HIV/AIDS Apr 1

st_2005‐

Sep 30th 2010 20,682,531 Round 5 Tuberculosis Comprehensiveness and Quality of DOTs in Sudan Jan 1

st_2007‐ Dec 31st 2011 11,684,917 Round 5 HIV/AIDS Scaling up the National Response for prevention and treatment of HIV/AIDS in Sudan Jan 1st 2007‐ Dec 31st 2011 84,976,035 Round 7 Malaria Scaling‐up Malaria Interventions in Northern Sudan Apr 1

st_2009‐ Mar 31st 2014 77,156,461 Round 8 Tuberculosis Addressing TB control in war‐affected, post conflict areas and other challenges Jan 1st_2010‐ Jun 30th₂₀₁₀ 3,171,523 Round 8 HSS Addressing TB control in war‐affected, post conflict areas and other challenges Jan 1st 2010‐ Jun 30th 2010 714,791 SSF TB/HSS Comprehensiveness and quality of DOTs in Sudan Addressing TB control in war‐affected, post conflict areas and other challenges Jul 1st 2010‐ Feb 28th 2015 45,267,705

HIV R10 To intensify the HIV/AIDS national response in Sudan Mar 1

st_2011‐ Feb 28th 2013 19,180,279 Malaria R10 Scaling up for Universal Coverage with Community Participation Mar 1st 2011‐ Feb 28th 2013 53,673,711 Total 349,748,406

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Table 2: Overview of the total approved, received funds and expenditures until December 31st 2012

Grant Name Approved Received Expenditures Balance

Round 2 Malaria Phase 1 14,237,853 14,237,853 13,156,250 Phase 2 19,002,600 18,840,189 19,206,292 715,500 Round 3 HIV/AIDS Phase 1 7,842,140 7,842,140 7,181,565 Phase 2 12,840,391 12,185,910 11,749,546 1,096,939 Round 5 Tuberculosis Phase 1&2 11,684,917 11,684,917 11,684,917 0 Round 5 HIV/AIDS Phase 1 29,421,145 29,421,145 18,372,150 Phase 2 55,554,890 44,017,230 49,184,423 5,881,801 Round 7 Malaria Phase 1 28,503,242 35,373,169 25,027,861 10,345,308 Round 7 Malaria Phase 2 48,653,219 26,012,413 21,080,039 15,277,682 Round 8 Tuberculosis Phase 1 7,207,041 3,171,523 3,171,523 0 Round 8 HSS Phase 1 8,292,492 714,791 714,791 0 SSF TB/HSS Phase 1 19,851,519 20,129,456 15,587,385 4,542,071 SSF TB/HSS Phase 2 25,416,186 0 0 0 HIV R10 Phase 1 19,180,279 4,338,391 2,524,573 1,813,818 Malaria R10 Phase 1 53,673,711 27,353,645 19,813,874 9,568,860 Totals 361,361,625 255,322,772 216,426,101 38,896,670

UNDP/GFATM PROJECTS

1.1 OVERALL GOALS, OBJECTIVES AND ACHIEVEMENTS

Malaria

1.1.1 Scaling up Malaria Interventions in Sudan

The overall goal of the Scaling‐up Malaria Interventions

(SMI) in Northern Sudan Project (Round 7 grant) which started in April 2009, is to continue and expand disease management activities implemented under the previously closed project on Malaria Prevention and Control (Round 2); which included home based management of malaria, improvement of clinical and

Figure 1: The Launch of the 8thcampaign for Bed Net distribution. This picture is from Blue Nile State, Damazin locality. The State Governor, State Minister of Health , Undersecretary Federal Ministry of Health, Locality Governor and UNDP Project Officer handing over bed nets to mothers. Project supported by the GF, UNDP and UNICEF

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laboratory diagnosis, ensuring availability and rational use of anti‐malarial drugs, establishing a Malaria Early Warning System (MEWS) to ensure a rapid response to malaria outbreaks.

The other aspects of malaria case management in this project are a gradual shift from clinical, symptomatic , treatment to test‐based treatment by introducing the use of rapid diagnosis test kits, preventing malaria during pregnancy through the distribution of bed nets and capacity building of national institutions. Another objective of this project is to unify and standardize interventions by all NGOs working in the field of malaria control in Sudan in line with the national framework. The Round 10 Malaria, as new grant that started in March 2012, intends to scale‐up and reach

universal coverage with community participation by bridging the gaps observed in Round 7 as well as the introduction of IRS (in‐door Residual Spraying) for vector control for locations with an in intensive irrigation schemes; mainly Gezira and Sennar states. In addition, the grant is aimed at strengthening the organizational capacity of national counterpart and provides support for Malaria Program Review. Main Achievements in 2012  2, 894, 862 cases of uncomplicated and severe malaria cases received anti‐malarial treatment according to National guidelines.  3, 106, 115 bed nets were distributed to protect approximately 6,212,890 people from malaria.  4, 330 health facilities were supported to continue the provision of free anti‐malarial drugs throughout 2012.

 2, 229 dispensaries in rural and hard‐to‐reach parts of the country were fully supported to continue providing free Rapid Diagnostic Test for malaria.

Figure 2: Blue Nile State: Children demonstrating bed net use to members of their community – Project supported by GF, UNDP and UNICEF

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HIV/AIDS

1.1.2 Scaling up the National Response for prevention and treatment of HIV/AIDS (Round 5)

The overall goal of the Scaling up of the National Response for prevention and treatment of HIV/ AIDs project (Round 5 grant) is to contribute to reduce HIV transmission and HIV mortality in Sudan. The project aims to increase awareness of HIV/AIDS and other STDs further enhancing and reducing risk behaviours; and to ensure availability and utilization of quality VCCT services in all states; increase access to condoms through free distribution, social marketing and other outlets in target communities. In addition, the project targets that more than eighty percent of blood transfused in government hospitals is from non‐remunerated voluntary donors. The project has also a major component for care and support services to PLWHAs.

Main Achievements in 2012 HIV R5 Main Achievements

 The project reached over 168,000 people from the general population through community outreach Behavior change communication (BCC) interventions.

 BCC interventions provided to 137,335 for members of Most at Risk Populations (MARPs) and vulnerable population (youth in IDPs).  BCC interventions reached more than 4, 000 young people from out‐of‐school settings.  More than 85,000 people have completed HIV testing and counseling process.  About 5,500 people with advanced HIV infection are receiving ARV combination therapy.  2,032 TB patients have begun ART during or at the end of their TB treatment. 1.1.3 Intensify the HIV/AIDS national response in Sudan (Round 10) The characteristics of the HIV epidemic in Sudan mirror that prevailing in the Middle East and North Africa (MENA) region. HIV infection is concentrated among high‐risk populations with vulnerable populations being the bridge of HIV transmission into the general population.

It is with in this context that the Round 10 HIV project, which is launched in 2012, aims to to reduce HIV transmission and to reduce HIV morbidity and mortality in Sudan. Objectives 1. To reduce HIV transmission through the provision of services for MARPs. 2. To improve access and utilization of PMTCT services in Northern Sudan. 3. To improve quality and uptake of existing care and treatment services in Northern Sudan. 4. To strengthen HIV prevention in health care settings in Northern Sudan. 5. To improve planning, management and monitoring of the HIV/AIDS response

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Cross‐cutting Issues:

‐ TB/HIV is another cross‐cutting issue that is targeted in this project with training voluntary counselling and testing for TB patients as well as condom distribution.

‐ The project is targeting the 17 states with focus on war affected areas and conflict zones with activities and capacity building in the form of refurbishment of localities warehouses as well as upgrading of locality staff capacity in planning and communication.

‐ Income generation activities target Most‐at‐risk populations (MARPs) to empower sex workers with life skills, information and support needed to make informed decisions on their current and future life and to abandon sex work or to reduce their risky behaviour. Study conducted in 2008 in Khartoum state among FSWs showed that, 80.2% were selling sex due to economical reason, and more than 21% do not use condom because their partners refuse.

Round 10 HIV: Main Achievements in 2012

 Reached 4,487 MARPs (MSM&FSW) through peer education.

 Provided counselling and testing services to 60,036 people including pregnant women and MARPS.

 79 pregnant women received ARVs to reduce the risk of mother to child transmission of HIV.  Trained 151 health care providers on syndromic management of STI according to the national

guideline and 59 health care providers trained on Infection prevention in health care settings.  Retained 2,574 people on ARV treatment.

Tuberculosis

and

Health

System

Strengthening

1.1.4 Single Stream Funding (SSF) – TB and Health Systems Strengthening Programme (SSF‐ TB/HSS)

The overall goal of the TB component of this project is to drastically reduce the TB burden in Sudan, particularly among poor and vulnerable populations in line with the 2015 MDGs and the Stop TB Partnership targets. The project aims to decrease the burden of TB through reducing mortality, morbidity and transmission of the disease until the disease no longer poses a threat to public health in Sudan. It also aims to reduce human suffering and the social and economic burden which families and communities have to bear as a consequence. The project aims to scale up and strengthen quality DOTs including creating access to war‐ affected and post conflict regions; strengthen partnership including PPM and engagement of health care providers; prevent and control MDR‐TB, and address TB contact management; as well as raise awareness and participation of communities and politicians, including the creation of positive perceptions toward TB

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prevention, treatment efficacy and adherence, in addition to reducing stigmatizing attitudes the burden of TB/HIV in Patients and PLWHA.

1.1.5 Single Steam of Funding (SSF): Health System Strengthening

The goal of the Health System Strengthening component of the SSF grant is to contribute to improving the performance of National health system for a better response to the three diseases to achieve MDGs, including MDG‐6 for AIDS TB and Malaria. This cross cutting project aims to improve health services delivery including laboratory services, assuring quality and equity of access at all levels of health care; strengthen health management information system, including surveillance and setting up a M&E system for measuring the health system’s performance; strengthen the procurement and management system for drugs, supplies and equipment, including quality assurance; as well as quantitatively and qualitatively scale up the availability of Human Resources for Health at

different levels of health care; and finally strengthen health financing function of health system for assuring

equity and access to health service. Main Achievements in 2012 Tuberculosis • TB treatment was provided to 19,831 TB cases. • The project detected 6, 518 new smear positive TB cases. • 70.6% of reported new smear positive TB cases were successfully treated. • 254 TB cases were diagnosed as MDR‐TB cases and placed on treatment. • 190,589 condoms were distributed to TB patients. • 2, 827 people were trained on TB management, contact tracing and management, PPM, DOTS links and health communication skills. Figure 5: Mini‐buses delivered to Academy of Health Sciences to commute Students to and from hospitals/ Field appernteship to their Academies Figure 4: Upgrading Rural Hospitals, Primary Health Care centers & Laboratories by equipping & furnishing Figure 3: Vehicles: to enhance the capacity of Locality Health Management Teams, as part of the overall HSS programme.

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• 27 TBMUs were newly established in Darfur states. • 54 DOTs were newly established in Darfur states.

Health System Strengthening (HSS)

• A health system strengthening project implementation mechanism was created within the Ministry of Health and the CCM, including establishing a HSS sub‐CCM committee

• Site assessment and design work for rehabilitation of the Academies of health Sciences finalized; and civil work is on‐going to be realized by June 2013. • 14 Academies of Health Sciences in 14 states were provided with minibuses to facilitate their daily work and commute students between health facilities, the academies and communities. • Equipments to upgrade five rural hospitals, 25 health centers, 15 laboratories & five health academies were procured & handed over to MOH. • 293 health management personnel from 114 localities trained in decision‐making, teamwork, effective meetings, and health planning and district health management

• The capacity of Locality Health Management teams enhanced by the provision of vehicles, office equipments and computers.

• 25 participants from states and federal level trained on M&E of the health system; out of which 5 staff was nominated to participate in external advance training on M&E will be conducted in Liverpool University.

• 42 health managers from states and localities trained in health economics/financing. • A framework for community based health insurance (CNHI) has been designed.

• Five fellowships in health economics & health care management were awarded in collaboration with the National Health Insurance Fund & University of Chulalongkorn, Bangkok, Thailand.

• 20 health managers from states & localities were enrolled in health economics/financing 4 week in country short course in collaboration with the National Health Insurance Fund & University of Chulalongkorn, Bangkok, Thailand.

• A new implementation strategy was developed in light of the changes in the implementation arrangement for phase II.

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1.2 PROJECT MANAGEMENT

UNDP as Principal Recipient of the GFATM grants has the primary role in ensuring that the implemented activities, undertaken by sub recipients (SRs), contribute to the national response against HIV, TB and malaria. At the state and locality level the implementation is carried out by SNAP, NTP and NMCP states’ coordinators. WHO, UNFPA, UNICEF, UNAIDS and UNHCR are the major Sub‐Recipients responsible for the management and provision of technical support in areas of treatment, prevention and awareness raising activities for the various projects, while the UNDP as the Principal Recipient oversees the management and implementation, including the release of funds and tracking of their use. To ensure the proper management and execution of grants, the Global Fund Programme Management Unit is divided into eight sections‐ four sections managing the specific grants (HIV, Malaria, TB and HSS), a Monitoring and Evaluation, Finance, Procurement and Supply Chain Management sections. The PMU adopted a standard operating procedure for efficient and proper implementation of all GFATM grants. UNDP’s standard project management framework and internal controls govern the project execution. The project is also staffed with the relevant programme, Finance, procurement and other support personnel. In addition, all grants undergo the regular and periodic review and assessment by the Local Funding Agent (LFA) which is contracted by the Global Fund. UNDP has also annual audits

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1.3 PROCUREMENT

1.3.1 Details of the construction activities under all grants

Delivering adequate health services in Sudan was severely affected by prolonged conflicts and instability in the country. UNDP, through the Global Fund support and in‐collaboration with local partners, has taken the lead in health system strengthening initiatives which include rehabilitation and renovation of health infrastructure; as well as capacity building and improving the skills of health personnel.

As part of advance procurement planning, a Request for Proposal for the Provision of Services for Rehabilitation/Construction Works in Sudan was launched at the end of 2011 for pre‐qualified national and International Engineering and Consulting Firms to engage them under Long Term

Agreement (LTA) for one year to participate in the civil works as per the 2012 PSM Plans. Accordingly, a Long Term Agreement was signed with consulting firms in April 2012.

1.3.2 HIV/AIDS Grant‐ Construction and rehabilitation of health facilities

Under the Round 5 HIV/AIDS grant, the Certificates of Final Completion have been issued for 78 constructed and rehabilitated buildings in 15 States of Sudan. The Sudan National Programmes have taken over these buildings with the full responsibility of the maintenance.

Construction of two (2) Centres for HIV‐Prevention of Mother to Child Transmission (PMTCT) ‐ is ongoing at a cost of USD 325,440. The progress as of December 2012 stood at 75% completion. Procurement of one hundred and eighty six (186) Split Unit Air‐conditioners and Outdoor Pavements and furniture for health facilities was planned and implemented at the cost of USD 670, 031. This is part of a project to upgrade the HIV healthcare facility infrastructures throughout the 15 states. The targeted facilities include 80 HIV healthcare facilities which were constructed between 2010‐2011. The facilities include VCTs, PMTCTs, ART, Blood banks and offices of PLWHA Associations.

1.3.3 Ensuring and improving drug storage conditions

As part of improving the supply chain of drugs and other health products, UNDP has signed an agreement with the Central Medical Supplies (CMS) to take the overall responsibility of storage, distribution and handling of Global Fund funded drugs. UNDP has also constructed warehouse under Round 5 HIV/AIDS. The

Figure 6 Atbara Zonal Lab –Back view, after completion of the Civil Construction works

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procurement of Storage Racks, application of Epoxy flooring, installation of Central Air‐Conditioning System, Construction of internal partitioning, reconstruction of fences, and building of security rooms planned and initiated at a cost of USD 448,850. Epoxy flooring work for this central warehouse was completed in December 2012; with the remaining activities to be completed by March of 2013.

In addition, seven (7) Diesel Generators of 80 KVA capacity were procured for States and Regional Warehouses at a cost of USD 167,996.

Under the Round 7 Malaria grant, three Diesel Generators were procured for Malaria Institutes in Sinar, Khartoum and Gazeera States at a cost of USD 179,666

As part of refurbishing medical stores in different States, the remaining 4 locality medical stores –out of 107‐ in South Darfur States are supplied with shelving/racking systems. Diesel generators for 4 locality medical stores in South Kordofan are stored in Central Medical Supplies (CMS) Warehouse in Khartoum due to the current volatile security situation in the area.

1.3.4 SSF‐TB/HSS

Following a gap analysis done in 2011, refurbishment was planned under the SSF‐TB/HSS grant to strengthening of Tuberculosis Management Units (TBMUs) in post conflict areas including the rehabilitation of 18 TBMUs, 45 TBMU Laboratories and 54 DOTs centres, with an estimated budget of USD 519,000.

The improvement of infrastructure of the 18 TBMUs and 54 DOTS centres was achieved as per the approved plan for phase 1, by supplying and installing basic office furniture with a total cost of USD 32,130. All targeted facilities were successfully reached apart from 10 locations in Darfur where the supply and installation is expected to be completed by March 2013

Rehabilitation works for the National Reference Laboratory in Khartoum are completed at the cost of USD 154,522. The certificate of substantial completion was issued on August 2012 and the site was handed over to the National Programme. In addition, the National Reference Laboratory in Khartoum is supplied with 150KVA Diesel Generator at the cost of USD 33,860.69.

Three (3) Zonal Laboratories are being rehabilitated at the cost of USD 126,627 and will be handed over to National Programme by mid of March 2013.

To improve quality of TB services and to reduce MDR TB cases, construction of two TB MDR patient wards in Khartoum is held at the cost of USD 123,907. The construction work commenced in December 2012.

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The rehabilitation of another seven (7) Tuberculosis Quality Control laboratories and two (2) Zonal Laboratories is planned at the cost of USD 311,533; the rehabilitation is expected to commence by March 2013.

As part of upgrading the health facility infrastructures, five (5) Diesel Generators of 20 KVA capacity were procured for the TB Zonal Laboratories at the cost of USD 92,772.

1.3.5 SSF‐TB/HSS‐ rehabilitation / construction of the academies of health sciences

Following an assessment to verify the rehabilitation requirements for selected academies of health sciences, the plan for rehabilitation and construction of five (5) Academies of Health Sciences (AHSs) has been approved by the global fund with an estimated cost of USD720, 000.

Construction/ Rehabilitation of the AHSs is intended to improve the availability of Human Resources for Health at different levels of health care both quantitatively and qualitatively. Construction/ Rehabilitation of the five AHSs are being held at the cost of USD 650,000. The construction work has started since December 2012, with a planned completion by June 2013. Table 3: Summary of construction activities for all grants in 2012 Description of Procurement Grant/ source of funding Value (USD) Rehabilitation of the National TB Reference Laboratory TB 154,522 Construction of Two PMTCT Centres and Rehabilitation of Three (3) Zonal Labs HIV & TB 452,067 Procurement of (186) Split Units for HIV healthcare facilities in Different States in Sudan HIV 146,125 Procurement of Outdoor Pavements for HIV healthcare facilities in Different States in Sudan HIV 148,206 Procurement of Diesel Generators for (7) States Regional Warehouses, National TB Reference lab, (5) TB States Zonal Laboratories and (3) Malaria Institutes TB & Malaria 474,295 Procurement of Storage Racks, application of Epoxy flooring, installation of Central Air‐ Conditioning System, Construction of internal Malaria 448,850

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partitioning, re constructing the fence, and build security room

Procurement of 3 stand by Diesel Generators for Public Health Institute , Blue Nile National Institute for Communicable Diseases and Algadal Malaria Training Institute in Sennar Malaria 160,000 Construction of two TB MDR patient wards in Khartoum TB 123,907 Construction/ Rehabilitation of (5) Academies Of Health Sciences HSS 650,000 Rehabilitation Works for 7 Tuberculosis Quality Control laboratories and 2 Zonal Laboratories in Different States in Sudan TB 311,533 Table 4: Key pharmaceutical and non‐pharmaceutical products procured‐ 2012

Grant Name Description of Procurement Value (USD)

SSF‐TB/HSS IT Equipment 41,223 Round 7 Malaria Malaria Health Equipment (Lab) 215,233 Round 10 Malaria Anti Malarial Drugs ( ACTs) ‐Malaria 518,880 Round 7 Malaria Anti Malarial Drugs ( ACTs) ‐Malaria 4,365,492 Round 5 HIV/AIDS HIV/AIDS ARVs 757,638 Round 5 HIV/AIDS HIV/ AIDS drugs 128,673 Round 5 HIV/AIDS HIV/ AIDS Test Kits 121,814.40 Round 5 HIV/AIDS HIV/ AIDS Lab. Equipment 437,551.22 SSF‐TB/HSS Laboratory Equipment 896,792 SSF‐TB/HSS Hospital Equipment 935,714.42 SSF‐TB Second line Drugs 516,412 SSF‐TB First line Drugs 1,343,685 Round 10 Malaria RDT’s 632,520 Round 10 Malaria IRS+ Accessories 3,398,564 Round 10 Malaria Sprayers 395,370 Round 5 HIV/AIDS Furniture 218,661.15 SSF‐HSS Furniture 258,256

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SSF‐HSS Skill lab 34,058

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1.4 SUPPLY CHAIN MANAGEMENT

During 2011, UNDP/ GFATM, in close collaboration with partners, developed a strategic roadmap to strengthen the supply chain management system and identified key interventions for establishing a viable and agile supply chain system in the country. This project supports the national programmes in establishing a responsive and sustainable supply system capable of delivering appropriate, sufficient quality health commodities to the right places at the appropriate time and free of charge. Below are the key interventions in 2012.

1.4.1 Logistics Management Information System (LMIS)

UNDP/GFATM is supporting mechanisms aimed at providing reliable logistics data captured through a functioning LMIS in health facilities and transferred effectively and efficiently along the nationwide supply chain up to the CMS, national programs and UNDP. The reports to be delivered through the LMIS include National Physical Inventory reports, Stock Status reports, HIV/AIDS TB and Malaria commodities consumption reports, Patients per regimen reports and Expiry Risk Analysis reports.

1.4.2 PSM Technical Assistance

UNDP/GFATM contracted Axios Foundation as the PSM technical assistance provider to strengthen the national supply chains for HIV/AIDS, TB and Malaria programmes in Sudan; as well as assess the current logistic system. The foundation is to document the system’s strengths and weaknesses, as well as support the availability of an agile supply chain system.

Axios Foundation had completed the first year work plan as per the agreement. Major deliverables include the PSM system assessment, PSM system redesign & the support to the national forecasting & quantification technical working group, manual SCM system development, defined requirements for an electronic LMIS, and Training of PSM and CMSC staff. 1.4.3 Central Medical Store UNDP/ GFATM signed a Sub Recipient agreement with the CMS in 2011, with a mandate for the management of procurement and supply of pharmaceuticals in Sudan. The main objective is the delivery of a wide range of supply chain interventions to ensure consistent availability of products at all levels and to prevent treatment disruptions by establishing a sound and reliable logistics system.

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1.5 MONITORING AND EVALUATION

Monitoring and evaluation are indispensable learning and management tools for improving current and future program planning, implementation and decision making. Regular verification of data, and data quality assurance were among the priority areas for the UNDP/ GFATM M&E section throughout 2012. In order to avoid creation of an M&E system parallel to the national one, UNDP/ GFATM has exerted efforts into strengthening the latter. To guarantee collection of data for all indicators using data tools from national programs which feed the quarterly reports, UNDP/ GFATM, continued working in collaboration with all partners to review these tools to ensure all important information is captured, and data quality is maintained.

Towards the second half of the year, UNDP‐ GFATM PMU conducted HIV/AIDS Round 5 Outcome Evaluation Studies focusing on (i) Prevention; and (ii) Care and Treatment components of the program, as an effort to improve the quality and effectiveness of the national, multi‐sectoral response to HIV/AIDS in Sudan.

The evaluation revealed that program targets were achieved or exceeded except for those related to ART programme coverage and patient retention, and TB and HIV collaborative activities. Accordingly, the study recommended investigating the factors contributing to the low patient retention rates at ART centres. This evidence should then guide a national strategy to improve patient retention and ART adherence monitoring. The evaluation findings also emphasized the need to strengthen the ability to collect and interpret information regarding the progression of the HIV epidemic and the influence of the country’s unique socio‐ cultural dynamics on the uptake and utilization of care and treatment services. Such effort would allow continually monitoring the relevance of the HIV care and treatment programme and adapting it accordingly.

The evaluation studies have underscored that the Round 5 HIV grant made a significant contribution to the HIV Integrated Bio‐Behavioural Surveillance Survey (IBBS survey project); the findings of which have established a baseline for the states and served as a means for generating strategic information to design appropriate interventions for the key populations.

During the fourth quarter of the year UNDP‐GFATM PMU and the LFA conducted On‐Site Data‐Verification (OSDV) for the TB & HIV grants and Rapid Service Quality Assessment (RSQA) for the HIV grant. The exercise was intended to verify reported results mainly focusing on treatment and training indicators. The OSDV & RSQA exercises covered selected health facilities in Khartoum, El Gezira and El Gadarif states.

The OSDV exercise made a number of recommendations including the need to develop standard operating procedures (SOPs) in order to guide the recording and documentation process at all levels. The need for an integrated and comprehensive database has also been highlighted through observations of the Global Fund,

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the Local Fund Agent (LFA) and various national partners. Observations and recommendations made during these visits were shared with the UNDP‐ GFATM PMU, CCM and partners.

In order to closely monitor the grant implementation, based on the findings of the shared quarterly reports, UNDP‐GFATM PMU, SRs and national programmes jointly conducted over 20 field visits to facilities supported with GF grants (10 field visits to the HIV/AIDS facilities, four visits to TB facilities, five visits to Malaria facilities, and two visits covering training related activities). Ten out of the seventeen states in Sudan were covered during those visits. The visits covered the data quality assurance, staff training status; facilities’ supply stock status which includes drugs and test kits; inspection of the warehouses for storage conditions of the drugs and test kits as well as expired supplies. Reports of the visits with findings and recommendations were shared timely with the implementing partners. M&E Related Achievements and Challenges in 2012: Major achievements:  Contribution to development of National M&E Plans for HIV/AIDS & TB Programs  Initiation of the first National TB Prevalence Survey  Contribution to the implementation of the National Malaria Indicator Survey (MIS)  Successful completion of two evaluation studies on HIV/AIDS prevention, care and treatment Major challenges:  Limited access in some states for M&E and supervision due to security related restrictions  Lack of National Strategic Framework on M&E  Poorly developed M&E systems & infrastructure especially at the state level  Lack of national policy or strategy on Health Management Information System (HMIS)  Poor progress in finalizing results of HIV/AIDS sero‐behavioural survey  High turnover of trained staff at all levels of the health system, especially at state level

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1.6 CHALLENGES, LESSONS LEARNED AND RECOMMENDATIONS

 Challenges Related to Security

In 2012, the volatile security situation in certain parts of the country posed constraints on the implementation and monitoring of project activities. This has been prominent in certain regions of the country, mainly in the Blue Nile, South Kordofan and several areas of Darfur States. The Darfur states were less accessible for supervision visits by national health cadres. Consequently, there is also a high turnover of trained state ministries’ of health staff which negatively impacted the timely reporting from the health facilities to the state and federal levels. Uneven distribution of health workers in the country, especially the shortage in security volatile and hard to reach areas has continued to negatively affect access to and quality of services.  Challenges related to programme implementation Although the unpredictable security situation in many parts of the country posed a continued challenge to the activities; security challenges are not the only problem facing GFATM projects. At the national level, although information/ statistics of the prevalence rates of the three diseases is available, there is a lack of information on the quality and access to health services available throughout the country.

Additionally, the monitoring role of the local administration at the state levels is limited. The sustainability and ownership of all the programmatic activities at the state levels is crucial to the sustained control of the three diseases and strengthening the health system in Sudan. However, the changing and limited leadership role of the local administration continues to be a challenge.

At the national level, there is a substantially high rate of medical staff turnover due to the economic challenges facing medical staff throughout the country; as well as brain drain. Finally, the limited capacity of national CSOs when trying to access GFATM funds is problematic. Since the UN and GFATM requirements for funding are quite strict, this has deterred access of local and national organisations working with the three diseases. However, by September 2012, the GFATM Board has modified the additional safeguard policy imposed on Sudan and partially approved the direct access to resources by government entities and CSOs. This is a major and positive development in terms of creating capacity and reaching most hard to reach communities in the country. Although in 2012, there were several activities focusing on capacity building of national NGOs, this remained to be a challenge throughout the year.

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1.7 FOCUS AREAS FOR 2013

In line with UNDP’s major intervention and the modified Additional Safeguard Policy, UNDP as a PR will be engaging several government implementing entities and NGOs to directly implement Global Fund grants as key Sub‐recipients. This new implementation arrangement will start with TB and HSS grants while other grants will adopt this arrangement gradually in the years to come. In this context, UNDP will be implementing several Capacity development activities to national entities and NGO implementing partners, mainly focusing on Program management and institutional capacity. In this regard, preparations are underway since late 2012 to hold several trainings on grant management, financial management and compliance and Monitoring and evaluation. Another major area of engagement for UNDP in 2013 is the alignment of GFATM programs with the recent reform introduced within the Ministry of Health. Reform created and merged several programs into respective directorates with significant changes in role and responsibilities. This transition requires a close follow up and coordination, while ensuring the continuity of service delivery and achievement of the different targets set for GFATM grants. With regard to specific grants, UNDP along with the relevant partners will be focusing on the following major areas of work in 2013: Round 7 Malaria Grant  To continue delivering the first line drugs for malaria treatment free of charge to more than 4, 630 health facilities with special focus on IDPs, refugees and peripheral communities.  To enhance malaria vector control interventions through the distribution of approximately 1.3 million long lasting insecticide bed net to targeted communities.

 To strengthen the procurement and supply system by refurbishing 4 malaria warehouses in South Kordofan state.

 To continue upgrading the capacity of malaria control staff at the sub national level by conducting various training courses in the field of malaria.

 Completion of Malaria Indicator Survey (MIS) by March, 2013 and dissemination of the report

Round 10 Malaria Grant

 Completion of Malaria Programme Review (MPR) to assess where the programme stands and to update the national strategic plan for malaria control in the country with special focus on the national M&E plan.

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 Continue supporting the implementation of M&E e‐database to strengthen the malaria surveillance for timely reporting as well as timely feedback. This will be done in conjunction with the ongoing national effort to unify the health management information system (HMIS)  To equip malaria sentinel sites with computers and internet services to monitor the malaria trends to contain malaria outbreaks.  To distribute more than 2.3 million lasting insecticide treated bed nets to protect approximately 1.5 million people including pregnant women and children under the age of 5.  To continue supporting IRS intervention in Gezira and Sennar states Round 5 HIV Grant  Ensure the proper and complete closure of the round 5 HIV grant and finalize the implementation of activities which were part of the grant close plan. Round 10 HIV Grant  To provide HIV testing and counseling services for at least 400,000 people from the general population and 2,700 MARPs.  To provide ART for a minimum of 217 HIV positive pregnant women as part of MTCT of HIV  To provide ART services to 5,000 adults and children with advanced HIV infection.  To distribute 2.5 million condoms for free through health facilities and community based out‐ lets. Tuberculosis (SSF TB)

 All procurement for 2013 for Laboratories (equipment & consumables), 1st_{line and 2}nd_{line drugs}

have already been procured with staggered deliveries as per the needs and forecasted delivery dates. Pharmaceuticals/Health Products, non‐pharmaceuticals and services worth of $2,530,401, $1,725 & $196,214, respectively will also be provided in 2013 to support the program and improve access and quality of services.

 In 2012 equipment and furniture for TBMUs, DOTS centres & TBMU Labs have been requested. The furniture for the 18 TBMUs and 54 DOTS is already delivered and installed in the respective facilities while additional 5 Zonal Labs & 10 QC Labs will be equipped in 2013 once the on‐going physical renovations of these facilities is completed.

 Renovation of all 10 QC labs & 35 TBMU labs, 5 Zonal Labs 2 wards of Abu Anja MDR Hospital will continue and is planned to be completed in 2013.

 Preparation for all three TB surveys is completed during 2012 including the Drug Resistance Survey (DRS), KAP survey and TB prevalence survey. These surveys will be conducted in 2013 and2014.

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 The PR through its TB, finance & M&E team will continue to enhance and improve the capacity of the National counterparts especially the new SRs such as NTP, Epi‐Lab & STPA through on the job trainings, supportive Supervision, training on Monitoring and Evaluation, reporting, and financial, accounting and book keeping.

 Detailed targets set to be reached in 2013 interims of service delivery; case detection, treatment and other programmatic indicators are provided in the annex of this report.

Health System Strengthening

 The health system strengthening project is a cross cutting project, addressing the mainstream health care delivery in areas of governance, health care delivery, health information systems, and human resources for health, pharmaceutical supply management and service delivery. These components of the project are wrapped around and cross cut the different functions of the health system ensuring project deliveries. In 2013, the main focus is to enable government counterparts and the Ministry of Health manage GFATM projects directly by themselves. This entails, In light of the additional safe guard policy applied by the Global Fund, engaging new SRs, especially the government, requires a lot of capacity development and risk management interventions. In 2013, organizational leadership, management, transparent decision‐making and ensuring accountability systems are in place

 In addition, the regular HSS interventions in areas of service delivery, HMIS HRH, PSM and Health care financing will continue. In this regard, additional rural hospitals will be upgraded, referral laboratories will be equipped and furnished, Primary health care centres will be provided with the necessary medical equipments and furniture, more focus will be given in training newly recruited CHVs; a total of 570 in 2013. Additional two AHSs will be renovated and equipped. The IT infrastructure will be supported to galvanize the government’s effort to streamline and consolidate the HMIS system. Locality and State Health management teams will be provided both technical and material support.

CONCLUSION

This Annual report is intended to capture the main achievements of the year. However, it is worth underlining the importance of the huge efforts exerted by all stakeholders involved. The GFATM has gone a long way since the beginning of activities in 2005. Although there is a lot to be praised; we hope that the coming years will sustain previous achievements as well as accomplish further successes. All those involved understand that the road was a difficult one and there is also a lot to look forward to in the coming years head; with the hope that finally all the people of Sudan will enjoy the benefit of a healthy life.

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Annex I: Indicators

Annex I.1: Malaria Round 7 Indicators Update‐ 2012

Indicators Target Results Percentage

Health facilities providing free anti‐malarial drugs (equivalent number of health facilities will be provided) 4,630 4,330 94% Communities (villages, nomadic groups, settled IDP camps) have access to ACTs through HMM programme 290 287 99% Dispensaries using (free) RDTs for malaria diagnosis 2,406 2,229 93% Localities with at least 2 malaria control staff trained in different aspects of malaria control 80 68 85% Localities with warehouses having adequate storage conditions 100 103 103% Localities with standard procurement and supply system in place 105 105 100% Health service providers trained in laboratory techniques, PSM, IVM, epidemic control, HMM, and treatment of cases (doctors, nurses, lab technicians, medical assistants) 7,383 5,965 81% Public health officers completing training in medical entomology and vector control 68 68 100% Cases of uncomplicated and severe malaria receiving anti‐ malarial treatment according to National guidelines 2,500,000 2,894,862 116% Number of ITNs distributed 3,412, 905 3,106,115 91%

UNITED NATIONS DEVELOPMENT PROGRAMME

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Table of Contents

Acronyms

EXECUTIVE SUMMARY

Sudan Map

BACKGROUND AND INTRODUCTION

UNDP/GFATM PROJECTS

Malaria

HIV/AIDS

Tuberculosis

and

Health

System

Strengthening