2009 Sudan: Evaluation of UNICEF-GOS 2002-2006 Country Health and Nutrition Programme
The baseline situation of women and children before the start of the 2002-2006 UNICEF Health and Nutrition Programme can be described from MICS 2000. This survey reported child (under 5) mortality and infant mortality in northern Sudan were 104 and 68, respectively. ARI, malaria, diarrhoea, combined with malnutrition were identified as the main causes of child deaths. A prevalence rate of 28.2% for diarrhoea, 16.7% for ARI were found in U5 children in northern Sudan in 2000.
MICS 2000 data also indicated that approximately 64.5% of children received a BCG vaccination by the age of 12 months. The coverage for measles vaccine was 51.5%. There was a considerable drop out rate for the second or third dose of DPT and Polio. The first dose of DPT and Polio was given to 65.9% and 74%, respectively. The third dose of DPT and Polio dropped to 46.2% and 44.2%, respectively. The percentage of children who had all eight recommended shots was only 26.4% in northern Sudan.
15.7% children under age five in Sudan were wasted (moderate and severe) and 3.8% were classified as severely wasted, according to MICS 2000. Approximately 31% of babies weighed less than 2500 grams at birth. About 44% of children received a high dose Vitamin A supplement. Approximately 19% of children aged less than four months in northern Sudan were exclusively breastfed.
Overall, 22.8% of U5 children were reported having fever in the last 2 weeks prior to the survey. Only 22.5% of febrile children got appropriate malarial treatment. Coverage of insecticide-treated nets within U5 children was only 2% though 24% of U5 children used a bed net, according to MICS. Only 0.6% of households had adequately iodised salt.
According to the SMS 1999, the MMR was 509 per 100,000 live births. According to MICS 2000, about 70% of the women in northern Sudan received antenatal care from skilled personnel. Skilled personnel delivered about 87% of births (midwives and trained-TBAs delivered 43% and 29% respectively). Only 21% of married women had ever used a method of family planning and 7% were currently using a method. Little activity had been done for HIV/AIDS in Sudan before 2002, though a prevalence of 1.6% was reported that year. The distribution of health facilities and health personnel was not equitable. On average, in 2002, less than half (43.6%) of all health facilities in northern Sudan offered RH services and some services, like EmOC, were seriously lacking.
The objective was to carry out a comprehensive end of cycle evaluation for the health and nutrition programme within the context of UNICEF–Sudan Country Programme of Cooperation 2002-2006 to gain an understanding of the successes and failures during the implementation, draw lessons learned and make recommendations based on the findings. The evaluation was intended to establish an evidence–based policy making framework to influence all the forthcoming policies and strategies for effective learning and to assist in the future planning of the 2009-2012 country programme.
The following methods were used: desk review, key informant interviews, cost-benefit analysis, field visits and data analysis.
Findings and Conclusion
Results showed that UNICEF deserved strong praise for its central role in the provision of primary health, immunisation, child health and nutrition, emergency essential heath care services in Sudan.
During the 2002-2006 programme cycle, UNICEF provided valuable support to the government in accordance with its obligation as set out under the Convention of the Rights of the Child, to protect and promote the rights of children to survival, development, protection and participation.
The dimension of the assistance from UNICEF was comprehensive. These dimensions included advocacy at policy level, service delivery on the ground, institutional support at federal and state level, and capacity building of service/care providers. UNICEF supported the establishment and rehabilitation of health facilities and provision of equipment, supplies and essential medicines.
Routine operation and campaign activities were supported, as well as fund raising, programme design and planning, joint monitoring and supervision. In addition to these activities in focus states, the programme also covered activities in non-focus states with respect to projects of national thrust (namely EPI, emergency planning and response, malaria control, HIV/AIDS and micronutrient
The years 2002-2006 were a period during which the country had not yet recovered from its decades of conflict. It was a period when natural and man-made emergencies frequently occurred with considerable impact on the population. The period also carried a mix of frustration and hope, ups and downs; during which many sectors demanded development and was a period in which primary health, child and maternal health care were waiting to build momentum. Despite the many constraints the programme had faced, it ended by fulfilling some of its targets and reaching noticeable achievements.
The major achievement of the programme was progress in immunization. UNICEF consistently provided leading support on routine immunization service, ranging from expansion of fixed sites delivery immunization, provision of vaccines and cold chain equipment, to training vaccinators and programme managers. As a result, the capacity of routine immunization in Sudan has largely improved across planning, management, information reporting, and surveillance. Health facilities with EPI service increased from 40% to 75%. Overall coverage of routine immunization, DPT3 as an example, increased from 70% to 85%. Together with other partners including WHO, UNICEF provided support on supplemental immunization activities such as polio NIDs, measles campaigns, and vaccination activities to prevent diseases such as meningitis, yellow fever, hepatitis, and tetanus.
Though polio was not eradicated, reported cases and outbreaks which had been devastating in the past were largely avoided.
The second achievement of the programme was the effort exerted on Malaria control. During the latter half of the programme period, reported malaria cases and deaths were continuously decreasing. This was largely due to the combined improvements on prevention, diagnosis and treatment. UNICEF contributed to all these preventive and curative measures, with supplies of long lasting Insecticide treated nets, provision of ACT anti-malaria drugs, capacity building and upskilling of lab technicians and health workers, and with institutional support to malaria departments and their human resource development. During field visits, it was observed that primary health care providers showed confidence and skills in handling malaria cases. Supplies and management were an integral part of routine service delivery.
During 2002-2006, there were many emergency situations, due to conflict, natural disasters such as flooding, disease outbreaks, and Darfur crisis. UNICEF proved to be always available whenever and wherever the need was required. In addition to technical assistance and capacity building support, UNICEF was responsible for provision of supplies, such as life saving and essential drugs, vaccines, supplementary & therapeutic feeding supplies, PHC kits, health education materials, safe delivery kits, mosquito bed nets & insecticides, Non Food Items such as jerry cans, and water treatment. The coordination procedures and processes within UNICEF and externally with its partners have ensured that it fulfilled its core planning commitments towards emergency situations in Sudan, by conducting an assessment of the emergency situation within 48 hours, and being able to release prepositioned supplies to assist 35,000 persons within 10 days, for a period extending to 2 months.
UNICEF supported the primary health care system, through the establishment and rehabilitation of health facilities, provision of PHC kits and other equipment, the training of first-tier health providers to deliver essential care to address the main child diseases responsible for preventable child mortality.
UNICEF, together with UNFPA, shared the responsibility to support midwifery school training, provision of midwifery kits, and installation of EmOC services. This effort, though still need more inputs to yield major reductions in maternal mortality, ensured greater access to quality basic obstetric care for many women previously without access. A number of nutrition surveys and sentinel surveys in northern Sudan were conducted with the support of UNICEF. UNICEF also supported Vitamin A supplementation through Polio NIDs, iodized salt consumption through policy and legislation and provision of iron supplementation to pregnant women. Through the activities of NGOs, the operation of SFCs and the TFCs were jointly supported by WFP and UNICEF. Though this strategy might not be the long-term solution to reverse children’s malnutrition status in conflict areas, it ensured that child malnutrition was not deteriorating in the country.
The HIV/AIDS intervention during the cycle targeting vulnerable groups, such as youth and women, was slowly rolled out at the beginning, but was in a better position at the end of programme cycle.
Seven PMTCT centres were established and operational in South Darfur, Khartoum, Kassala, North Kordofan, and Red Sea states. Those who tested HIV positive were subsequently provided with ARV treatment.
The GoS-UNICEF 2002-2006 programme did not achieve an impact on reducing child mortality and maternal mortality rates, based on the limited data available. The broader impact of the programme , which could not be measured in numbers, was evidenced in process indicators, like improvements in ANC delivery, deliveries by skilled personnel, reductions of disease burden and PHC provision to women and children. Positive effects of inter-sectoral activities between health, education, water and environmental sanitation in addressing mortality rates were also observed.
There was a noticeable impact on the programme environment. A variety of policies and plans were designed at both National and State levels. At the grass root level, community was aware of the Programme. The concerns of families about child immunization, child nutrition, child rights and disease prevention were strengthened. Despite its fragility in some areas, a peaceful environment became conducive to the various activities of the Programme. Previous areas of conflict started to return to normal allowing various activities to be sustained.
In light of the SHHS results, and as part of the extensive joint planning exercises undertaken across the health sector, key opportunities to have a distinct impact on the overall environment included promotion and implementation of the Accelerated Child Survival Initiative (ACSI). ACSI attempted to scale up existing projects, especially the Expanded Programme on Immunization and nutrition, while identifying capacity and resource shortfalls and prioritizing specific activities at local, state and national levels.
The following suggestions are advanced for consideration in the design of the coming programme cycle, which we would hope will accelerate progress towards MDGs.
1) Continue ongoing policy development and enhance its implementation. Development of state strategies and policies is needed.
2) Initiation of a systematic integrated human resource development policy, with solutions to stop brain-drain at top, provide career ladder at bottom. This should include mechanisms to encourage the health cadres serving the people in rural areas, and opportunities for state and
federal health officers to obtain rural field experience.
3) To guard against sudden fluctuations in the flow of funds, there is need to develop a strategy for programme sustainability to be gradually and smoothly introduced, enlist government commitment to sustainability.
4) There should be a shift of focus from emergency to sustainable development. More focus should go to identify gaps in service delivery and filling these gaps, and to take a balance between service expansion and quality of the service. More focus is needed on communities with
potential for quick-win at population level, rather than remote disadvantaged communities.
5) More focus on prevention, community health, rather than cure to break the cycle of disease transmission.
6) More focus on providing essential services to the communities in rural areas and training their first-tier service providers, rather than nurturing academic training that is not suitable for rural populations.
7 ) Improve programme design with clear defined indicators and targets versus known baseline, combine impact and outcome indicators with process indicators and targets to be checked and monitored annually.
8) Develop a comprehensive monitoring and evaluation plan to be used for the programme cycle.
9) Continue decentralized management, and improve budgeting. Federal level should shift focus on policy/guidelines/protocol development, planning support, supervision, monitoring and evaluation.
10) Improve programme implementation and its quality, with effective coordination, with more attention to routine management, and quality of supervision.
11) Improve the quality of the primary health care service through guidelines, effective management and supervision. Explore the potential of primary health first-tier service providers to provide integrated service such as community health, nutrition, and obstetrics care.
12) Continue the support of midwifery schools, provide reproductive health services, and improve the quality of obstetrical care. Expand PMTCT service.
13) Continuous improvement of routine immunization service, enhancing the coverage, improving supervision and raising the efficiency of immunisation, providing service and strong coordination across borders with neighbouring countries, creating a balance between routine
activities versus campaigns, and identifying gaps to be filled by real supplementary service.
14) Health information should be strengthened. Routine data collection and data quality issues should be addressed. States and localities should have clear instructions regarding which health information items are essential for collection and how/when to collect them and how the
data can be used. Maintaining the political stability will help the health information collection and its trend analysis.
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