Darfur Health Assessment

UNCLAS SECTION 01 OF 05 KHARTOUM 001181

SIPDIS

AIDAC
SIPDIS

STATE FOR AF/SPG, PRM, AND ALSO PASS USAID/W
USAID FOR DCHA SUDAN TEAM, AF/EA, DCHA
NAIROBI FOR USAID/DCHA/OFDA, USAID/REDSO, AND FAS
USMISSION UN ROME
GENEVA FOR NKYLOH
NAIROBI FOR SFO
NSC FOR JMELINE, TSHORTLEY
USUN FOR TMALY
BRUSSELS FOR PLERNER

E.O. 12958: N/A
TAGS: EAID PREF PGOV PHUM SOCI KAWC SU
SUBJECT: Darfur Health Assessment

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Summary and Comment
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1. Since the escalation of the conflict in Darfur in
2004, coordinated efforts within the humanitarian
community have resulted in substantial improvement in the
overall health and nutrition situation of conflict-
affected communities. These advances are evidenced by a
declining trend in crude mortality rates (CMR) and rates
of global acute malnutrition (GAM) to levels below
emergency thresholds. The North, South, and West Darfur
State Ministries of Health (SMoH) are collaborating with
U.N. and international non-government organization (NGO)
partners to coordinate health and nutrition
interventions, conduct cross-sectoral planning
specifically linked with water and sanitation
interventions, improve communicable disease and nutrition
surveillance systems, control communicable diseases,
provide community health and nutrition education, and
increase access to primary health care (PHC),including
reproductive health and nutrition services.


2. However, recent improvements in health and nutrition
trends may soon be undermined by a variety of factors.
Reduced donor funding has forced NGOs providing health
and nutrition services to discontinue essential
programming activities. The effectiveness and efficiency
of humanitarian operations in Darfur are also constrained
by limited access to insecure areas, frequent population
movements, logistical shortfalls, high turnover of SMoH
staff, and increasing government restrictions on
international aid workers. Across Darfur, the health
education sub-sector remains under-prioritized, and is
often the first health intervention to be downsized as a
result of reduced donor funding. Additionally, Darfur's
resource-intensive curative methodology - which focuses
on treatment rather than prevention - relies heavily on
external donor funding, leaving both international
organizations and the SMoH vulnerable to resource
pipeline shortfalls. Furthermore, the standard of care
offered under the current system may not be transferable
to local health care providers following the resolution
of conflict in Darfur.


3. Looking forward, USAID recommends that U.S.
government (USG) agencies working in the health and
nutrition sectors of Darfur seek to strengthen existing
primary health care and nutrition programs by directing
future funds towards community-based activities in order
to maintain their sustainability into the future.
Funding should also be provided to maintain and expand
health and nutrition early warning and surveillance
systems, as well as strengthen the expanded program of
immunizations (EPI) and national immunization days (NID)
including measles. Finally, health education initiatives
focused on preventing acute respiratory infection,
diarrhea, and malaria have great potential to achieve
widespread behavior change and improve health throughout
the region if they are implemented and supervised
correctly. End summary and comment.

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Visits and Contacts
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4. From April 23 to May 3, 2006, a USAID/OFDA Health
Specialist traveled to North Darfur and South Darfur to
assess the local health and nutrition situation and
monitor OFDA-funded health programs in the region. In
Khartoum, the health specialist met with a Khartoum-based
USAID Medical Officer, U.N. agencies including the U.N.
Children's Fund (UNICEF),U.N. World Health Organization
(WHO),U.N. World Food Programme (WFP),and U.N.
Population Fund (UNFPA),and OFDA implementing partners
Action Contre la Faim (ACF),International Medical Corps
(IMC),Save the Children-U.S. (SC/US),and World Vision
International. In El Fasher, the specialist met with
representatives from the North Darfur SMoH, Relief
International (RI),GOAL, UNICEF, WHO, and UNFPA. While
in North Darfur, the specialist accompanied GOAL health
promotion, nutrition, and medical coordinators and a

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doctor from the Kutum Ministry of Health (MoH) on a site
visit to internally displaced person (IDP) camps in Kutum
and Kassab. She also accompanied representatives from
UNICEF, WHO, and the International Rescue Committee (IRC)
on a site visit to Abu Shouk and Al Salaam IDP camps. In
Nyala, the health specialist met with representatives
from IMC, IRC, the American Refugee Committee (ARC),ACF,
WHO, and UNICEF and conducted site visits to Kalma camp
with ACF and IRC, to Al Salam camp with IMC, and to the
ARC clinic in Nyala.

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Health Assessment
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5. Coordination: The health and nutrition sectors are
coordinated by WHO and UNICEF, respectively. Both U.N.
agencies are functioning appropriately as sector leads.
However, coordination for the Health Education sub-sector
is weak, with a failure to standardize methodologies
leading to erratic use of information materials,
variations in training methodology, and inadequate
community follow-up for behavior change. Funding
shortfalls which have forced WHO to cut human resources
will significantly weaken regional coordination
mechanisms and reduce WHO's ability to support Darfur's
SMoH health surveillance and disease prevention
activities. Funding shortfalls have also resulted in
program cutbacks in critical resources such as community
health workers, community based services, and knowledge
surveys.


6. Health Surveillance, Trends, and Capacity: According
to WHO, Darfur's CMR of 0.46/10,000/day and under 5
mortality rate (U5MR) of 0.79/10,000/day are both below
the emergency threshold levels of 1/10,000/day and
2/10,000/day percent established by the Sphere Project.
The WHO-supported Early Warning and Alert Response System
(EWARS) for reportable diseases has improved local
capacity to detect communicable disease incidents and
trends in many of Darfur's IDP camps. However, the
reporting rate declined from 66 percent to 40 percent in
2005 as a result of insecurity, reduced humanitarian
presence, and IDP population movements. Routine
surveillance in areas not supported by international NGOs
remains challenging due to continued insecurity and the
logistics requirements needed to maintain ongoing data
collection activities. Laboratory facilities lack
necessary supplies and transportation challenges lead to
difficulties in the proper collection and analysis of
samples. Darfur's SMoH capacity for independent
operations is constrained by a limited budget, and the
general scarcity of human resources, equipment, and
logistics capacity. Thus, local authorities rely heavily
on international partners for health surveillance as well
as disease prevention and treatment.


7. Morbidity and Mortality: According to WHO, the
leading cause of mortality in Darfur across all age
ranges is acute respiratory infection (ARI). Diarrhea
(19 percent in North Darfur and 14 percent in South
Darfur) and acute respiratory tract infections (ARI) (31
percent in North Darfur and 25 percent in South Darfur)
account for the majority of the current morbidity rates
for children less than 5 years of age. The current all
age group malaria morbidity rate of 4 percent is expected
to increase between June and September as a result of
impending seasonal rains. Outbreaks of mumps and
seasonal cases of meningitis in 2005 and 2006 were both
controlled by rapid detection and response.


8. Preventive Medicine: Routine EPI coverage for
diphtheria, pertussis, and tetanus in children less than
one year of age among target populations has improved to
61 percent in the third quarter of 2005 (from 32 percent
in the first quarter of 2005). Though vitamin A, iodine,
and de-worming medications are not routinely administered
under the EPI program, these items are distributed to
children during irregularly scheduled National
Immunization Days (NID). Measles and vitamin A coverage
in UNICEF's target areas is 73 percent and 86 percent
respectively. Darfur's EPI program is currently facing

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coverage gaps due to general insecurity, lack of
resources, and difficulty in maintaining cold-chain
storage and transport of immunizations.


9. Environmental Health: In an effort to improve
management of response to public health emergencies in
Darfur, WHO has adopted a system to correlate
environmental health indicators (water quality
management, solid waste management, and vector control)
with communicable disease control and prevention
activities. This cross-sectoral link has allowed for
rapid detection of disease, identification of the disease
source, and enabled immediate intervention to stop
further disease transmission at the onset of an outbreak.
As a result, the Darfur region has experienced fewer
disease outbreaks than the rest of Sudan. Resource and
funding shortfalls necessitating reduced staffing for
epidemiologists and environmental health threaten this
critical linkage.


10. Primary Health Care Delivery: According to OCHA,
access to PHC services in target communities is currently
at 80 percent. However, health and nutrition services in
IDP camps throughout Darfur function on a clinically
based methodology that is unsustainable for both Darfur's
State Ministries of Health and the international
community. Diagnosis and treatment of diseases in camps
is difficult to assess, but the USAID health specialist
found extensive evidence of costly health care practices
such as unwarranted drug prescriptions, over-
administration of IV/IM drugs, extended length of in-
patient care, and ineffective triage. Darfur's State
Ministries of Health have adopted the Integrated
Management of Childhood Illnesses (IMCI) protocol.
However, the USAID health specialist was unable to find
these guidelines at any of the clinics she visited during
her time in Darfur. NGOs provide most out-patient
referrals while WHO funds most hospital and medical
logistics activities. NGOs managing critical drug
supplies reported infrequent shortages of essential
medicines. IDPs are currently receiving health care free
of charge, but the international community is evaluating
beneficiary cost-sharing mechanisms to create a more
sustainable system which can eventually be transferred to
Darfur's State Ministries of Health.


11. Reproductive Health: Reproductive health care
services, including antenatal, delivery, and post-natal
care, are available at hospitals and NGO-supported health
facilities in Darfur's major population centers. The
region's maternal mortality ratio is currently estimated
at 630 maternal deaths/100,000 live births. (Note: This
estimate is based on incomplete data collected from
hospitals and NGO clinics. Eighty percent of women in
Darfur continue to deliver at home.) Safe motherhood
services are available to 60 percent of women of
childbearing age in UNFPA-targeted communities.


12. Malaria: The regional annual malaria prevalence
rate peaks shortly after the rainy season. The control
strategy for malaria in Darfur consists of clinical
treatment with appropriate antibiotics (combined
therapy),distribution of long-lasting insecticide
treated bed nets, and the use of environmental control
measures such as risk mapping and insecticides in IDP
camps during the peak malaria season. Bed nets are
currently available to only 41.6 percent of targeted
households, and their appropriate use in the home has not
been documented at the community level.


13. HIV/AIDS and SGBV: The prevalence of HIV/AIDS in
Darfur is currently estimated at 2.7 percent. Though
current testing rates are very low (only 16 people were
tested in El Fasher in the last 2 years),OFDA
implementing partners are beginning to increase HIV/AIDS
education and prevention activities. Advocacy by the
international community has improved case management and
treatment guidelines for victims of sexual and gender
based violence (SGBV). State Ministries of Health are
currently reviewing SGBV management Protocols drafted by
the MOH and the international community. UNFPA provides
rape kits to NGOs for medical management. However, there

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is currently no universally recognized SGBV surveillance
mechanism for Darfur and NGOs have encountered difficulty
in accessing post exposure prophylaxis (PEP).

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Nutrition Assessment
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14. Trends: According to the December 2005 Darfur
Emergency Food Security and Nutrition Assessment
published by WFP, UNICEF, and the U.N. Food and
Agriculture Organization (FAO) in cooperation with
Sudan's Government of National Unity (GNU),the nutrition
situation in Darfur had improved and stabilized over the
course of 2005. The prevalence rate of GAM in children 6-
59 months of age has decreased from 21.8 percent in 2004
to 11.9 percent as of September 2005 and severe acute
malnutrition (SAM) has decreased from 3.9 percent in 2004
to 1.4 as of September 2005. The report attributed
improvements in nutrition indicators to improved food
security, lack of disease outbreaks, and the
establishment of a functioning nutritional surveillance
system.


15. Surveillance: UNICEF collects nutritional
information by conducting standard 30 x 30 surveys and
coordinating routine nutrition surveillance at 12 urban
feeding centers or rural sentinel sites in each of
Darfur's three states. Recent NGO assessment surveys
indicate that pockets of malnutrition persist in North
Darfur. Additionally, the recent improvement in
nutrition trends in Darfur is now threatened by a 50
percent reduction in food rations which coincides with
the beginning of the regional hunger season.
Micronutrient deficiencies including vitamin A, iron, and
iodine are prevalent in children and women of
reproductive age. Funding shortfalls resulting in
reduced humanitarian presence will likely result in
significant information gaps and undetected pockets of
malnutrition throughout the area over the coming hunger
season.


16. Feeding Programs: Admission rates to selective
feeding programs have declined to less than half the
number of admissions recorded in May 2005. Community
therapeutic care (CTC) is being implemented in 80 percent
of selective feeding programs, but to varying degrees by
OFDA's various implementing partners. CTC protocols are
not standardized, training is costly and therefore
inaccessible, and the State Ministries of Health
administer traditional more costly TFCs (note: USAID/OFDA
and Global Health are planning to support CTC training in
several regions in Africa including Sudan). Cure rates,
mortality rates, and default rates for therapeutic
feeding centers (TFCs) are consistent with Sphere
standards. However, the supplementary feeding center
(SFC) default rate of 39 percent is more than twice the
international standard of 15 percent established under
Sphere standards. The high SFC default rate may be
linked to a general dissatisfaction with the corn soy
blend (CSB) distributed in many feeding programs,
maternal time constraints, or population movements linked
to a variety of local factors. Exclusive breastfeeding
for children less than 6 months old is above 65 percent.
Health and nutrition education is provided at community
clinics but requires routine follow-up.

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Recent Health and Nutrition Gains Threatened by Funding
Cuts
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17. USAID should strengthen existing health programs in
Darfur prior to expanding health services into rural
communities. Currently, NGOs and Darfur's State
Ministries of Health do not have adequate financial and
technical capacity and are struggling to ensure the
continued health of the people of Darfur.


18. USAID Health Specialist recommends the following
course of action to consolidate, stabilize, and advance
health and nutrition in Darfur:

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a) Coordination: Support WHO and UNICEF to staff and
coordinate health sector humanitarian interventions in
Darfur, including efforts to control communicable
diseases and monitor environmental health, in order to
avoid impending gaps due to funding shortfalls.

b) Surveillance: Support WHO to continue disease
surveillance via EWARS and build the capacity of Darfur's
State Ministries of Health to ultimately assume
responsibility for managing this important system.
Current methods of data collected through NGOs operating
in IDP camps and host communities should be expanded to
include non-camp populations as capacity allows. Expand
Darfur's nutritional surveillance system - including
surveys, feeding center data, and sentinel site
information - as capacity allows. These systems are
critical for early detection and response to public
health emergencies in order to avoid massive disease
outbreaks and increases in malnutrition rates.

c) Primary Health Care: Support existing basic PHC
services in IDP camps and affected host communities.
Where possible, support a local PHC structure that serves
both IDP sites and host communities to improve capacity
of Darfur's local health systems. Strongly promote the
implementation of cost-effective community-based methods
such as clinical and community IMCI. Improve triage
procedures and strengthen coordination between health
NGOs to reduce patient load as well as support community
based therapy when appropriate. Support routine EPI and
NIDs including vitamin A, de-worming medicine, and iodine
distributions. Continue funding commodities such as
basic essential medicines, vaccines, medical supplies,
and nutritional products containing micronutrients.
Continue to build local SMoH capacity to manage health
finances, medical training, and drug inventory and
control systems.

d) Selective Feeding: Provide technical support to
increase health sector and community capacity to
implement Community Therapeutic Care (CTC) programs in an
effort to decrease long, costly inpatient nutritional
care (note: this will be funded by USAID). Investigate
the high SFC default rate and apply lessons learned to
improve program efficacy.

e) Health Promotion: Monitor community based health and
nutrition interventions to closely measure behavioral
change. Strengthen community health and hygiene promotion
activities by supporting sub-sector coordination and
funding collaborative joint knowledge, attitudes, and
practices (KAP) surveys. Encourage NGO collaboration to
use these KAP surveys to formulate community training
guidelines, standard training protocols, and information,
education and communication (IEC) materials. Support the
development of a joint monitoring system to follow up on
KAP surveys and measure behavioral change. The
association between positive behavioral change and the
corresponding decrease in disease rates cannot be
overemphasized. Maintain and prioritize transferable
health interventions - including malaria prevention,
diarrhea prevention, health seeking behavior, home based
care, safe feeding practices, growth monitoring, and
breastfeeding. Avoid expansion of medical clinics into
new communities and focus attention to build and sustain
IDP knowledge of community health best practices.

HUME