Sudan on 15 August marked a historic first for the Global Fund, submitting a consolidated concept note that included all three disease components plus health system strengthening, in order to access the $131 million it was allocated under the new funding model (NFM).
The consolidated approach to accessing Global Fund support is in line with a new national health strategy working towards complete integration of all health services at the primary facility level in the country of 37 million. Developed in 2012 to run through 2016, the national health strategy aims to ensure universal health coverage through the expansion and decentralization of the primary health care system.
"This was not something initiated by the Global Fund but by the country itself; they realized that in light of their limited resources and the possibility of cost efficiencies, integration and decentralization was the only way forward," said Fund portfolio manager Maxim Berdnikov. "So vertical programs are now working towards integration at all levels, especially with the primary health system, with the goal of ensuring access to quality PHC services for all citizens".
Dr Imad Kayona, director of international health for Sudan's Federal Ministry of Health, explained in an email that a situational analysis showed that the country's health system, including service delivery, was characterized by its fragmentation, which meant that there were multiple and parallel systems for virtually every component of health service delivery including procurement, supply and training. That fragmentation meant that there were missed opportunities throughout the system to provide services to an underserved population.
According to the analysis, 14% of the population of Sudan had no access to health services; further, only 24% of the existing health facilities provide the minimum and basic primary health care package.
Taking its consolidating cues from two other Global Fund implementing countries -- Ethiopia and NFM early applicant Myanmar -- Sudan embarked on a comprehensive review process that included a complete overhaul of its data collection and analysis, recognizing there were substantive gaps in its mapping of disease and population. The review resulted in two costed extensions -- for HIV and for malaria, both of which were approved in April 2014 -- for existing grants so that the work on devising a coherent concept note based on sound data could continue without interrupting service delivery.
"The ultimate goal of all of the data management work was to improve the national strategic response [to all three diseases]," said Berdnikov. "For malaria there is now a comprehensive epidemiological understanding, and a robust approach to addressing the past weaknesses in program delivery. The major data gaps that contributed to the suboptimal prioritization of the HIV program have been resolved. And data collection is continuing in order to understand the high default rate for TB, to identify the weaknesses and update the national strategic plan to deliver better programming for TB services."
Among the data challenges that were overcome, with programs and studies funded by development partners including the Global Fund, was an efficiency-driven streamlining of reporting systems. This helped to improve aggregation and identify the states and localities that were plagued by under-reporting: a function, in part, of the tumult and political upheaval that followed the formal secession of South Sudan in 2011.
The tumult in Sudan has not, however, ceased since secession. Regular flashes of conflict erupt in three of the most marginalized states in the country -- Darfur, South Kordofan and Blue Nile -- interrupting and at times even suspending service delivery. But where the Fund has a unique advantage in Sudan that it does not in other countries that grapple with conflict and post-conflict scenarios is in its close relationship with the other humanitarian actors providing services either with, or in substitution for, the national health service.
"There's no donor overlord in Sudan like in other countries, and there is an independent billion-dollar Darfur Development Fund that can be used to support health programs, so we always have the possibility of alignment with UN partners and others," said Berdnikov.
With the submission of its concept note, Sudan is now waiting for assessment and review by the technical review panel, a process expected to begin in coming weeks.
Dr Kayona noted that already, the process of entering and implementing the NFM was providing a good opportunity for Sudan, "to further scale-up efforts aiming at bringing programmes together to work in an integrated environment. We believe that to ensure a successful implementation of the integration it is better to start at the planning phase. [We have found that] the challenges and bottlenecks facing the programmes and impacting their abilities to improve their outcomes are similar so the approach to address these challenges should be the same."
Among the programs being established and monitored in the interim, even as service delivery continues, is an effort to improve the workings of the country coordination mechanism, which in the past has been plagued by challenges, bottlenecks and a failure to monitor achievements.
"The CCM has been encouraged to address the issues of community systems strengthening, human rights, equity and access," said Berdnikov. "A legal review for the three diseases, looking at legal barriers to access for key populations was started in May and should be finalized in August, with an action plan ready for grantmaking. So things have improved, and we have things to improve further."