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Scaling up the malaria response in Sudan: putting evidence based pro-poor strategies into practice.

Situation:

Malaria is the leading cause of morbidity and mortality in Sudan. Symptomatic malaria accounts for 20-40% of outpatient clinic visits and approximately 30% of hospital admissions. The entire population of Sudan is at risk of malaria, although to different degrees. In the northern, eastern and western states malaria is mainly low to moderate with predominantly seasonal transmission and epidemic outbreaks. In southern Sudan, malaria is moderate to high or highly intense, generally with perennial transmission. P. falciparum is by far the predominant parasite species.

In 2001, a national 10-year strategic plan was developed; in 2002, the Khartoum and Gezira Malaria Free Initiatives were launched; in 2003, a plan was developed for scaling up the use of insecticide-treated nets (ITNs) including using communication for behavioural impact; and in 2004 a national policy for control of malaria in pregnancy was initiated. Importantly the drug policies have also been updated: in 2004, the national drug policy was updated to use the ACT Sulfadoxine-pyrimethamine plus Artesunate for first-line treatment in north Sudan, while amodiaquine plus artesunate was selected as first line treatment in southern Sudan.

Response:

The key strategies in a malaria control programme in countries with high transmission are ensuring coverage with ITNs, prompt access to effective treatment and Intermittent Preventative Treatment (IPT) for pregnant women. Ensuring these reach the poorest and most vulnerable populations is a challenge. Our focus has therefore been on pro-poor strategies, for example through supporting work with internally displaced people (IDPs), returning IDPs or by ensuring national policy decisions are implemented at all levels by supporting cascaded training to even the most rural health centres.  The Malaria Consortium is supporting the Ministry of Health in strengthening partnerships and building capacity; improving access to case management; improving access to interventions for pregnant women; improving access to ITNs; establishing a system to monitor the scale up response and; implementing malaria control in IDP camps in Darfur and Khartoum.

Specific activities to date have included:

In northern Sudan

  • Supported the National Malaria Control Programme in developing case management training materials and training of trainers courses on these materials.
  • Supported the training of doctors in 5 northern states on case management of malaria,
  • Provided training materials to support training of 1,000 doctors and 1,500 medical assistants.
  • Conducted management capacity strengthening with the National and state Malaria Control Programs
  • Developed the implementation guide for home based management of malaria
  • Supported the training of midwives on malaria in pregnancy interventions in 7 states.

In southern Sudan

  • Supported the MoH Government of Southern Sudan to develop their 5 year strategic plan, and their surveillance system  
  • Provided technical assistance to development of the anti-malarial drug policy
  • Supported the development of case management training materials and training activities
  • Supported the development and implementation of the malaria in pregnancy policy.
  • Developed a draft monitoring and evaluation framework for the health sector in Southern Sudan
  • Supporting the initialization of work on integrated vector management guidelines.
  • Provided technical assistance to the proposal for global funds.

Points to note:

Due to the priority of Federal MoH to implement and fulfill the requirements of malaria activities under the Global Fund, many activities under this project in north Sudan have been delayed. However, those activities complementary to Global Fund have been executed. MC Sudan Staff

In the north, free ACTs have been provided to all Global Fund states, and in 2007 this will be extended to non-global Fund states through support from donors. One impediment is the poor quality of diagnostic services, which hinders accurate diagnosis of malaria. Efforts are underway to investigate the implementation of Rapid Diagnostic Tests (RDTs) in smaller health facilities which do not have microscopic services, to improve this situation. The Malaria Consortium has conducted training on RDTs in the Darfur region where this method of diagnosis is used in 95% of the health facilities.

Other impediments to this project include the inaccessibility of approximately a sixth of the population in the North due to conflict and displacement, the extreme low density of the population, making access, especially in the wet season difficult.

In Southern Sudan, work is on track. A program coordinator has been appointed and office opened in in Juba.

A major impediment is the serious lack of human resource capacity in the south, at both GoSS and state level. However, this is slowly being overcome, with appointments to the malaria team at GoSS level, and the development of malaria control units at state level. The loss of trained staff throughout 21 years of civil war and the impact on war on routine educational services has left southern Sudan with a serious shortage in trained staff in all cadres. With the signing of the peace agreement, the trained diaspora are returning, and the situation is slowly improving.

 

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Photos: Malaria Consortium