Health System Strengthening (HSS) Cash Support
Application Package –Proposal Form
This proposal form is for use by applicants seeking to request Health
Systems Strengthening (HSS) cash support from the GAVI Alliance.
Countries are encouraged to participate in an iterative process with
GAVI Alliance partners, including civil society organisations, in the
development of HSS proposals prior to submission of this application
for funding.
TABLE OF CONTENTS
TABLE OF CONTENTS ........................................................................................ 1
PART A - SUMMARY OF SUPPORT REQUESTED AND APPLICANT
INFORMATION ..................................................................................................... 8
PART B – EXECUTIVE SUMMARY ................................................................... 11
PART C– SITUATION ANALYSIS ...................................................................... 14
1. Key relevant health and health system statistics ........................................... 14
2. Description of the National Health Sector ..................................................... 16
3. National Health Strategy and Joint Assessment of National Health Strategy
(JANS).............................................................................................................. 21
4. Monitoring and Evaluation Plan for the National Health Plan ........................ 23
5. Health System Bottlenecks to Achieving Immunisation Outcomes ............... 24
6. Lessons Learned and Past Experience ........................................................ 29
PART D - PROPOSAL DETAILS........................................................................ 32
7. Objectives of the Proposal ............................................................................ 32
8. Results Chain ............................................................................................... 37
9. Monitoring & Evaluation Framework ............................................................. 42
10. The Proposal Development Process .......................................................... 46
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PART E – BUDGET, GAP ANALYSIS AND WORKPLAN ................................. 52
11. Detailed Budget and Workplan Narrative .................................................... 52
12. Gap Analysis & Complementarity ............................................................... 54
13. Sustainability .............................................................................................. 57
PART F – IMPLEMENTATION ARRANGEMENTS AND RISK MITIGATION .... 60
14. Implementation Arrangements .................................................................... 60
15. Involvement of CSOs .................................................................................. 63
16. Technical Assistance .................................................................................. 65
17. Risks and Mitigation Measures ................................................................... 66
18. Financial Management and Procurement Arrangements ............................ 71
SUMMARY OF A COMPLETE APPLICATION .................................................. 79
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HSS Application Materials– 31/05/2013
A completed application comprises the following documents. Countries
may wish to attach additional national documents as necessary (see list
at the end of this form).
HSS Proposal Forms and Mandatory GAVI attachments
→ Please place an ‘X’ in the box when the attachment is included
No. Attachment
1. HSS Proposal Form
X
2. Signature Sheet for Ministry of Health, Ministry of
Finance and Health Sector Coordinating Committee
(HSCC) members
3. HSS Monitoring & Evaluation Framework
X
4. Detailed work plan and detailed budget
X
Existing National Documents - Mandatory Attachments
Where possible, please attach approved national documents rather
than drafts. For a highly decentralised country, provide relevant
state/provincial level plan as well as any relevant national level
documents.
→ Please place an ‘X’ in the box when the attachment is included
No. Attachment
5. National health strategy, plan or national health policy, or
other documents attached to the proposal, which
X
highlight strategic HSS interventions
6. National M&E Plan (for the health sector/strategy)
X
7. National Immunisation Plan
X
8. Country cMYP
X
9. Vaccine assessments (EVM, PIE, EPI reviews), if
X
available
10. Terms of Reference of Health Sector Coordinating
X
Committee (HSCC)
All applicants are encouraged to read and follow the accompanying
guidelines in order to correctly fill out this form. Each corresponding
section within the Guidelines provides more detailed instructions and
illustrative instructions on how to fill out the proposal form.
GAVI’s Approach to Health System Strengthening
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The following bullets outline GAVI’s approach to health system
strengthening and should be reflected in an HSS grant:

One of GAVI’s strategic goals is to “contribute to strengthening the
capacity of integrated health systems to deliver immunisation”. The
objective of GAVI HSS support is to address system bottlenecks to
achieve better immunisation outcomes, including coverage and
equity. As such, it is necessary for the application to be based on a
strong bottleneck and gap analysis, and present a clear results
chain demonstrating the link between proposed activities and
improved immunisation outcomes.

GAVI’s approach intends to deliver and document results. The
performance of the HSS grant will be measured through
intermediate results as well as immunisation outcomes such as
diphtheria-tetanus-pertussis (DTP3) coverage, measles coverage,
and percent of districts reporting at least 80% coverage. Therefore
the application must include a strong Monitoring & Evaluation
(M&E) framework aligned with the national M&E plan or national
M&E processes.

Performance based funding is a core approach of GAVI HSS
support.
All applications must align with the new GAVI
performance based funding (PBF) approach introduced in 2012.
Countries’ performance will be measured based on a predefined
set of PBF indicators against which additional payments will be
made to reward good performance in improving immunisation
outcomes.

GAVI supports the principles of alignment and harmonization (in
keeping with Paris, Accra and Busan declarations and the
International Health Partnership, IHP+). The application must
demonstrate how GAVI support is aligned with country health
plans and processes, complementary to other donor funding, and
uses existing country systems, such as for financial management
and M&E. The IHP+ Common Monitoring and Evaluation
Framework is used as a reference framework in these guidelines.

GAVI supports the use of Joint Assessment of National Strategies
(JANS). A JANS assessment is not a requirement for a GAVI HSS
application. If a country has conducted a JANS assessment the
findings can be included in the HSS application. The Independent
Review Committee (IRC) will use the findings of a JANS
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HSS Application Materials– 31/05/2013
assessment to gain an understanding of the policy and health
sector context that will inform their assessment of the credibility
and feasibility of the HSS proposal.
1

GAVI encourages a consultative and participatory approach for
developing this HSS proposal, particularly across relevant
departments in the Ministry of Health (including Planning, EPI,
HMIS, M&E), across development partners, and civil society.
While the HSCC (or equivalent) is required to sign off on this
application, the ICC (or equivalent) also needs to be consulted and
involved in the proposal development process.

GAVI encourages countries to request funding for technical
support in their HSS application for grant implementation,
monitoring and capacity building.

GAVI encourages countries to identify and build linkages between
HSS support and new vaccine introduction support (as GAVI New
Vaccines Support). These linkages must be demonstrated in the
application. Countries will need to demonstrate systems readiness1
for new vaccine introductions in the context of routine
immunisation services. GAVI HSS support will be for strengthening
these routine immunisation services.

GAVI’s approach to HSS includes support for strengthening
information systems and improving data quality.
Strong
information systems are of fundamental importance both to
countries and to GAVI. Countries are strongly encouraged to
include in their proposals actions to strengthen data systems,
including surveys and the institutionalization of routine
mechanisms to track data quality improvements over time.

GAVI supports innovation. Countries are encouraged to be
innovative in their identification of activities which will have a
catalytic effect on addressing HSS bottlenecks to improving
immunisation outcomes.

GAVI encourages applicants to include funding for Civil Society
Organisations (CSOs) in implementation of HSS support to
improve immunisation outcomes. CSOs can receive GAVI funding
through two channels: (i) funding from GAVI to MOH and then
For a definition of ‘systems readiness’ see: http://www.who.int/healthinfo/systems/sara_indicators_questionnaire/en/
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HSS Application Materials– 31/05/2013
transferred to CSO, or (ii) direct from GAVI to CSO. Please refer
to Annex 4 of the guidelines for further details.

Applications must include details on lessons learned from previous
HSS grants from GAVI or support from other sources.

Applications must include information on how sustainability and
equity (including geographic, socio-economic, and gender equity)
will be addressed.

Applications will need to show the additionality of GAVI support to
reducing bottlenecks and strengthening the health system, relative
to support from other partners and funding sources.

Cash disbursed for HSS support must be used solely to fund HSS
activities. These funds may not be used to purchase vaccines or
meet GAVI’s requirements to co-finance vaccine purchases, and
shall not be used to pay any taxes, customs, duties, toll or other
charges imposed on the importation of vaccines and related
supplies.
Application and Implementation Process
This application form has key instructions, but for more detailed
information please see the attached guidelines for completing a GAVI
HSS proposal. The application process for GAVI HSS proposals is
similar to the process of applying for new and underused vaccines. The
process of taking a decision to apply for GAVI funding and work with
GAVI Alliance partners to develop a proposal (Steps 1 and 2 in Figure 1
below) will require adequate time; as much as possible, it should be
planned to link with existing country planning processes.
Countries are encouraged to participate in an iterative process with
GAVI Alliance partners, CSOs and development partners in the
development of HSS proposals prior to submission of this application
for funding. Steps 1-7 indicate the standard steps for GAVI HSS
application process. Countries should allow 9-12 months for these
steps. Steps 1-3 are expected to take 3-4 months, while steps 4-7
typically take 6-9 months.
Please note that if approved your application for HSS support will be
made available on the GAVI website and may be shared at workshops
and training sessions. Applications may also be shared with GAVI
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HSS Application Materials– 31/05/2013
Alliance partners and GAVI’s civil society constituency for postsubmission assessment, review and evaluation.
Figure 1: Application and Implementation Process
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HSS Application Materials– 31/05/2013
PART A - SUMMARY OF SUPPORT REQUESTED AND APPLICANT
INFORMATION
For further instructions, please refer to the Guidelines for
Completing the HSS Application
Applicant:
Country:
Proposal title:
Federal Ministry of Health
Sudan
Health Systems Strengthening for
equitable Primary Health Care and
Immunization Services in Sudan, 2014-2018
Proposed start date:
May/2014
Duration of support
requested:
Five Years
Total funding
requested from
GAVI:
Contact Details
Name
Organisation and
title
Mailing address
33,231,766.0 USD
Mohammed Ali Yahia El Abbasi
Federal Ministry of Health, Sudan
Director General for Planning and
International Health
Directorate General of Planning and
International Health
Federal Ministry of Health, Sudan
P. O. Box. 303
Telephone
+249123390050
Fax
0024983780445
E-mail addresses
malikabassi06@yahoo.com
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HSS Application Materials– 31/05/2013
Signatures: Government endorsement
Please note that this application will not be reviewed or approved by GAVI without the
signatures of both the Ministers of Health & Finance and their delegated authority.
Minister of Health
Name: Bahar Idriss Abu Garda
Minister of Finance
Name: Badar El Deen Mahmoud Abbas
Signature:
Signature:
Date:
Date:
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HSS Application Materials– 31/05/2013
HSCC SIGNATURE PAGE
For submission with GAVI HSS application
Health Sector Coordination Committee
Country: Sudan
Date of HSS application: 22nd January 2014
We the members of the HSCC, or equivalent committee [1] met on 21st
January to review this proposal. At that meeting we endorsed this proposal
on the basis of the supporting documentation which is attached.
[1] Health Sector Coordination Committee or equivalent committee which
has the authority to endorse this application in the country in question.
Name of the HSCC in country NHSCC/HSS CCM Sub-Committee
Health Sector Coordination Committee
Name/Title
Agency/Organisation
Signature Date
Dr. Isameldin M.Abdallla
Undersecretary FMOH
Dr. Mohamed Ali Yahia
Elabbasi
Director General of Planning and
international health, FMOH
Dr. Talal Elfadil Mahdi
Director General of Primary Health
Care, FMOH
Dr.Igbal Ahmed Elbasher
Director General of Human Resource
for Health, FMOH
Dr.Imadeldin Ahmed
M.Ismaeil
Director l of International Health
Dr.Nagla Eltigani Elfadel
GAVI/GF Focal Person
Dr. Magdi Salih Osman
Director of EPI program FMOH
Dr. Dorothy Dchola
UNICEF Representative
Dr.Anshu Banerjaa
WHO Representative
Dr. Tatek Mamecha
UNDP Representative
Dr. Mohamed Sidahmed
UNFPA Representative
Mr.Sohaib Elbadawi
Rotary Representative
Dr. Mohamed Hussen
Humanitarian Aid commission
Representative
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HSS Application Materials– 31/05/2013
Dr.Mohamed Ahmed
Abdelhafez
CSOs Representative
Dr. Mohameed Osman
Director of National HIV/AIDS Control
Program
Dr. Hiba Kamal
Director of National Tuberculosis
Program
Dr. Fahad Awad Ali
Director of National Malaria Control
Program
Miss. Tayba Sayed
Ministry of Finance Representative
Dr. Osman Jafer
International Federation of Red
Cross/Red Crescent
Please tick the relevant box to indicate whether the signatories
above include representation from a broader CSO platform:
Yes 
No 
Individual members of the HSCC may wish to send informal comments to: gavihss@gavialliance.org
All comments will be treated confidentially.
PART B – EXECUTIVE SUMMARY
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HSS Application Materials– 31/05/2013
For further instructions, please refer to the Guidelines for
Completing the HSS Application
→ Please provide an executive summary of the proposal, of no more than 2
pages, with reference to the items listed below:
1. The main bottlenecks for achieving immunisation outcomes addressed
within this proposal and how proposed objectives in this application will
address these bottlenecks and improve immunisation outcomes.
2. Objectives and the related budget for each objective.
3. The proposed implementation arrangements including the role of
government departments and civil society organisations. Please include a
summary of financial management, procurement and M&E arrangements.
Sudan National Health Sector Strategic Plan 2012 – 2016 provides the overarching framework
and direction for different players in the sector to respond to the identified health challenges.
The country is facing economic difficulties due to the loss of 75% of its oil revenue as a result of
separation of South Sudan in 2011; the ongoing conflicts in some parts of the country and the
$40 billion debt. These constraints have hampered the primary health care services including
immunization and excavated the disparities between rural and urban as well as, disparities
between and within states and localities.
About 13.7% of the populations have no access to health facilities. A significant portion of
these are pastoralists and/or those living in conflict affected areas. Moreover, 39% of the
existing facilities are not fully functioning due to staff shortage or poor physical infrastructure.
Immunization services are provided in 76% of all functioning health facilities. As such, only 49%
of the target children are covered through fixed sites while 51% of them are covered through
the outreach/mobile strategy, with variations within and between states. The later strategies
for the EPI coverage are used in conflict affected areas. The volunteers, CSOs and NGOs are
playing considerable role operating this. The Health Management Information System (HMIS) is
largely fragmented, inconsistent and not inclusive. This is due to multiple, parallel vertical
disease based information sub-systems. The EPI is a typical example, it implements parallel
surveillance systems for five of the VPDs in a fragmented and vertical manner.
The inequity is remarkably reflected in the distribution of HRH, they are mostly concentrated in
capitals or major cities in the states. Nearly 70% of them are working in urban settings, of which
38% are in Khartoum state, serving only 30% of the population. EPI is much affected by this
situation, there is over dependence on volunteer vaccinators to provide immunization services
in most of the states. This coupled with shortage of cold chain technicians at all levels.
The governance, planning and management components are facing serious constraints. The
sub national tiers of the decentralized system are lacking appropriate, standardized structures,
planning and management capacities due to turnover in qualified staff.
The allocation of public funding has two major problems, firstly only 15% of the public health
expenditure goes to the PHC and other public health programs; secondly it is very inequitable
12
across
states.
HSS
Application
Materials– 31/05/2013
This proposal intends to address these bottlenecks to complement other partners’ efforts
through the following objectives:
Objective 2: To strengthen an integrated, comprehensive, efficient and sustainable Health
Information System in support of an evidence-based policy and planning: The planned
activities under this objective are geared towards integrating vertical programme. Institutional
capacity building for an integrated HIS is central to this proposal for improved efficiency,
where capacity development of HIS managers, data producers and analyzers shall be cared
for. Support would also be given to promising initiatives such as the community Health
Information System (CHIS). The planned activities in this area aim to scale up CHIS by
engagement of CHWs and utilizing the available networks of Community Health Volunteers.
Objective-3: To support production, equitable distribution and retention of a multi-tasked
facility and community health workforce to meet immunization and PHC needs: This objective
aims to scale up the recent shift from monovalent to polyvalent health workers. Efforts will also
be made to retain these health workers, especially posted in remote and hard to reach areas.
Objective 4: To strengthen management and leadership capacity of the decentralized health
system at state and locality levels for an effective and efficient implementation of an
integrated PHC package including EPI services. This objective aims to strengthen the
decentralized health system to ensure effective and efficient management of service delivery
which would in turn guarantee sustainability of the services. The activities intend to address the
factors hampering occurrences of essential changes required for strengthening the
decentralized health system.
The experience, strengths, weaknesses and lessons learned from the previous GAVI HSS/ISS,
and GFATM grants will be considered for the implementation of this grant.
Various implementation modalities will be used for the different contexts. In normal
circumstances where there is stability, FMOH will use its existing structures for delivery of PHC
services including immunization. On the other hand, in states and localities where there are
special needs, services will be provided through locally existing structures and by contracting
CSOs/NGOs as set out in the national health policy.
The implementation of the M&E activities related to the GAVI/HSS Grant will be carried out as
an integral part of the National M&E plan. The National M&E Plan and the broader HIS will
ultimately be the basis for reporting on the results of HSS support provided through the grant.
The Grant start date is May, 2014 in order to avoid interruption of EPI activities.
TWO PAGES MAXIMUM
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PART C– SITUATION ANALYSIS
For further instructions, please refer to the Guidelines for
Completing the HSS Application
1. Key relevant health and health system statistics
→ Please complete the table below providing the most recent statistics for the key
health, immunisation, and health system indicators listed.
→ Where possible, data on the key statistics should be presented showing wealth
quintile differences, and disaggregated by sex.
→ If available disaggregated data for the key statistics indicators showing
differences by geographic location (region / province) and urban / rural should be
included in the space provided after the table.
*Where possible, GAVI asks for both country administrative data as well as from
‘other’ data sources. Please state the source of ‘other’ data in brackets after entering
the value. ‘Other’ recommended data sources are DHS/MICS or recent coverage
estimates from WHO/UNICEF. If the difference between these reported data are
more than 5% points, the country should include an explanation as to how they plan
to strengthen data quality as part of the HSS grant.
Key Statistics
Indicator
DTP3
coverage
Measles 1st
dose
coverage
Drop-out rate
between DTP1
& DTP3
Percent of
districts
(localities) with
DTP3
Source
Administrati
ve Data
EPI national
coverage
survey
Administrati
ve Data
EPI national
coverage
survey
Administrati
ve Data
EPI national
coverage
survey
Administrati
ve Data
Other*
National
Average
Percentage
difference
between
highest &
lowest
quintiles
Sex
(Please provide
disaggregated data where
available)
M
F
Total
91.6%
NA
NA
NA
2012
84.3%
NA
84.3%
84.4%
2012
85%
NA
NA
80%
NA
80.3%
79.6%
8%
NA
NA
NA
9.8%
NA
9.8%
10.9%
(133/162) 82%
NA
NA
NA
2012
NA
NA
NA
-
NA
2012
2012
2012
NA
2012
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HSS Application Materials– 31/05/2013
Year
coverage
≥80%
DTP3
coverage in
the lowest
wealth quintile
is +/- X% points
of the
coverage in
the highest
wealth quintile
Fully
immunised
child
coverage (%)
Administrati
ve Data
NA
NA
NA
NA
- 44.5%
- 44.5%
NA
NA
2010
85% (measles 1st
dose coverage)
NA
NA
NA
2012
SHHS
Administrati
ve Data
2012
EPI national
coverage
survey
75%
NA
75.3%
74.4%
Additional Health System Statistics
Indicator
Under Five Mortality
Total Expenditure on Health
(THE) as percentage of GDP
Per capita expenditure on
health
Total health sector budget for
the year of application
Percent of the health sector
budget funded by the
government from domestic
sources
Budget of EPI programme for
the year of application
Percent of subnational level
facilities with cold chain
capacities fit for purpose
(based on WHO definition “fit
for purpose”)
Timeliness and completeness
of facility and district (or
equivalent) reporting
Source
Administrative
Data
Sudan
Household
health Survey
Administrative
Data
NHA
Administrative
Data
NHA
Administrative
Data
NHA
Value
Year
NA
83/1000 LB
2010
NA
6%
2010
111 USD
2010
1,069,279,647 USD
2012
NA
9.6%
28.9%
2012 IHP+
Annual
Performance
Report
2010
64,986,065.00 USD
2012
94%
2013
Other source
NA
-
Administrative
Data
Timeliness 95% (EPI)
Completeness 99% (EPI)
Integrated Reporting Rate:
Hospital 81%,
2012
Administrative
Data
NHA
Administrative
Data
Other source
Administrative
Data
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HSS Application Materials– 31/05/2013
% of expenditure for PHC out
of health expenditure
Other source
Administrative
Data
NHA
PHC 32%
NA
NA
-
15%
2010
N.B. ( NA= No Data Available)
Please use the space below to provide:
 Explanation of any disparities between administrative statistics and
‘other’ statistics and details of any plans to improve data quality to
address these disparities.
The discrepancy in EPI coverage indicators indicated in the table above is due to the fact
that the "Thirty Cluster" EPI Coverage Survey is designed with a level of precision of +/- 10%.
The observed discrepancy is within the precision level.
The existing EPI coverage survey tools do not provide disaggregated data to reflect the
differences between highest and lowest quintiles. The tools will be revised to allow data
disaggregation by gender, wealth and geographic location.
 Further disaggregation of the Key Statistics Indicators (if available). This
data will be used to illustrate equity differences by geographic location
and urban/rural.


Since 2005 Comprehensive Peace Agreement (CPA) till separation in 2011, the two parts of
Sudan (North and South Sudan) were having disaggregated data under one country.
Therefore, all data provided in this document are for Sudan (previously North).
EPI Coverage by State disaggregated by EPI Strategic Intervention 2012 is shown in the
attached table which includes list of localities (districts) with coverage less than 80% (Please
refer to Annex 6)
THREE PAGES MAXIMUM
2. Description of the National Health Sector
This section will provide GAVI with the country context which will serve as
background information during the review of the HSS proposal.
→ Please provide a concise overview of the national health sector, covering
both the public and private sectors, including CSOs, at national, sub-national
and community levels, with reference to NHP or other key documents.
→ Please include a copy of the National Health Strategy/Plan as Attachment
5. If the NHP is in draft format please provide details of the process and
timeline for finalising it. If there is not an NHP, or if other documents are
referenced in this section, please provide these other key relevant documents.
It is recommended that applicants refer to GAVI’s health system strengthening
grant categories detailed in the Application Guidelines (Table 1, Under ‘Key
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HSS Application Materials– 31/05/2013
Terms’). For each of the categories listed in the Guidelines (2.1-2.7) please
provide a short commentary. In order to keep this section concise, please
summarize the key elements in the context of the HSS support being asked for,
and provide reference to the relevant section in the National Health Plan for
further detail.
Service Delivery:
The health system in Sudan is three-tiered. The 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. Some responsibilities remain shared between the different levels
namely, early preparedness and response to disasters and epidemics, monitoring and
supervision and tertiary level care.
Public healthcare services are provided through a network of delivery points extending from
community healthcare, PHC (Family health units, Family health centres and rural/locality
hospitals), secondary and tertiary hospitals. These different levels are interconnected by a
referral system which is, however, not optimally functioning.
Health services are provided by different partners. In addition to National & State Ministries of
Health, other entities include; police and army health services, universities and National Health
Insurance Fund (NHIF) and the private sector (both for profit and non-for-profit). In areas
affected by conflict, Non-Governmental Organizations (NGOs) and Civil Society Organizations
(CSOs) have been playing a crucial role in service delivery. According to the Investment Plan
Survey, 2010 the majority of PHC facilities are government institutions of which 90% belong to
the Ministry of Health. The Health Insurance Program runs 3.9% of the facilities, while 2.9% are
affiliated to NGOs. However, many of these are performing in isolation due to an ill-defined
managerial system for coordination and guidance. The main structural challenges in the
government health services at different levels include the rigidity of the organizational structure
and poor coordination between departments.
Availability of PHC services is not uniform, with only 24% of facilities offering the Essential PHC
Package (reproductive health, immunization, nutrition, prevention and treatment of common
diseases and essential drugs). Immunization services, as part of PHC, are provided in 76% of
facilities. Outreach and mobile services continue to play a crucial role in expanding EPI
services, particularly in areas where there are no fixed EPI services due to lack of infrastructure,
geographic inaccessibility or humanitarian response situation as a result of conflict or natural
disasters.
Since 2005, Sudan successfully introduced four new vaccines in its routine
immunization programme, namely; Hepatitis B; Hemophulus influenza Type B; Rota Virus
Vaccine and PCV. This has been accompanied with considerable investment in cold chain
expansion. The huge dependency on volunteers, associated with high staff turnover, imposes a
huge pressure on the health system that has necessitated conducting frequent in-service
trainings and intensive supportive supervision at all levels to ensure sustained quality service
delivery.
Human Resources for Health
The health system suffered severe loss of human resources and uneven distribution, which is
evident between urban and rural areas, with 70% of health workforce working in urban settings.
Many rural areas are underserved by the health system in terms of functional facilities. PHC
minimum package provision is clustered around the cities with only 3.8% of the rural centres
and 21.9% of the family health units provide minimum PHC package. Therefore, one of the
major problems of Sudan’s health system delivery is the lack of optimal access to high quality
PHC services.
Pastoralists, rural poor and communities in conflict affected areas have poor access to PHC
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HSS Application Materials– 31/05/2013
services. Ensuring optimal access to PHC services is a challenge partly because the package is
provided in non-integrated manner. According to the Investment Plan Survey, 2010, the
shortage in staff has rendered 39.8% of PHC facilities non-functional. Increasingly, health
workers are forced out of the public health system to the private sector, from rural to urban
areas and migrate to other countries in search of better pay. Despite a national human
resources for health strategic plan (2012-16) being in place, to date the career structure,
incentive schemes, and mechanisms for retention and equitable deployment are not
operationalized.
In addition to the lack of uniform geographical coverage by essential health services, financial
(see also section on health financing) and socioeconomic barriers hinder the access to health
services. Among patients with acute ailments and chronic diseases, belonging to households in
the lowest income quintile, 1% and 0.2% respectively sought treatment. The corresponding
share among those belonging to the richest quintile is 2% and 1% respectively. In case of
ambulatory care, those belonging to the richest quintile utilized health services nearly four-fold
greater than those from poorest quintile (3.59% vs. 0.95%). Disparity in service utilization was also
witnessed in EPI services (see service statistics table and EPI coverage table by state Annex 6).
For more details please refer to NHSSP section 3.1.6 page 21.
Sudan is a diversified country whereby certain degree of gender disparities couldn't be ruled
out. However, There is lack of documented evidence to conclude existence of gender based
disparities in accessing PHC/immunization services in Sudan, which is an area for research. A
small scale gender gap analysis which has been conducted by Ahfad University for Women,
Sudan, revealed that girls and women have less opportunities for education, economic
participation, decision making and employment opportunities which could have negative
impacts on accessing and utilization of health services. In a positive note, volunteers providing
PHC/immunization services are, including CHWs and village Midwives, are predominantly
females. Upgrading their knowledge and information would contribute to addressing any
anticipated gender related service disparities.
Procurement and Supply Chain Management
All vaccines, injection supplies, and cold chain equipment for EPI that are co-financed by
UNICEF, GAVI HSS and Gov of Sudan are procured through UNICEF Country Office (CO)
including newly introduced vaccines and vaccines that are in the pipe line (IPV in 2014,
Mening quartet conjugate vaccine in 2016, Yellow fever in 2017). Procurement includes routine
vaccines (BCG, OPV, measles, and TT), and new vaccines (DTP/HepB/Hib, Rotavirus and PCV).
A five-year forecast for vaccines, injection supplies, and cold chain equipment is developed
and revised and updated annually jointly by UNICEF CO and the national EPI. Since 2008, the
EPI has built significant cold chain capacity largely through procurement of refrigerators and
cold rooms for the states. However, there is a dire need to further enhance storage capacity
for upcoming new vaccines, as well as a need for more refrigerated vehicles for the distribution
of vaccines. The EPI was also able to accommodate vaccines for various campaigns such as
polio, TT, meningitis A, measles and yellow fever.
Health Information Systems
The Health Information System (HIS) in Sudan is fragmented and paper-based. There are many
reporting forms catering for the different vertical and disease specific programs such as EPI, RH,
Nutrition and IMCI, in addition to the curative services utilization records at the level of health
facilities. The usage of computer software and ICT is limited and at low scale. However, with
support from the Global Fund and GAVI HSS, during the last two years data forms were
reviewed and modified with the objective of developing an integrated HMIS. In addition, a
process for digitizing the HIS has been piloted in two states using the District Health Information
System (DHIS-2) as a platform and is expected to be rolled-out gradually during 2014.
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HSS Application Materials– 31/05/2013
The Directorate of Epidemiology is responsible for the collection, tabulation, analysis and
distribution of epidemiological information on all diseases. Inopportunely, there is no clear
system in place for data quality assurance and data quality audit. So far, data quality
assessments are being conducted annually for GF supported programmes since 2011, in a
limited scale. Thus, under-reporting, delayed delivery of reports, poor local utilization of
collected data, and lack of a proper feedback system are common. Apparently the
corrective measures undertaken so far, including upgrading knowledge of statistics clerks,
couldn't improve the situation.
Given the above context, the EPI has been implementing a vertical approach for the routine
data management as well as surveillance. It also established an AFP surveillance system in
2000. To date, the system has achieved performance indicators at the level of certification.
Regular and active surveillance visits to all monitoring sites have greatly contributed to
upgrading the performance and follow up of indicators. Based on the achievements made so
far, the Ministry is embarking on integrating the various vertical surveillance systems into one
VPDs surveillance system. An integration manual was drafted in 2013 and will be endorsed and
implemented in 2014.
Generally, there is scarcity in data generation, including vaccine preventable diseases, to
support policy and planning for programming and service delivery. Two SHHSs carried out in
2006 and 2010 are the most comprehensive data source including main EPI indicators. The next
SHHS is planned for 2014. There were isolated attempts to address this problem. EPI provided
small scale support through training researchers, availing references materials, formulation of a
research proposal review and appraisal committee, preparation of research priority list and
supporting post graduate thesis on EPI related topics. In order to establish a dynamic and
responsive health research, government and partners need to put vigorous effort including
dedicating human and financial resources for research.
Community and other Local Actors
More than 100 local voluntary organizations operate in the field of immunization, with a focus
on states that are resource poor and/or conflict affected displaced population. More than
70% of these organizations operate in IDP camps in Darfur States and remote areas where
health services are weak or lacking. They provide logistic support and mobilize volunteers
during immunization campaigns which cover 90% of the population in Darfur, 70 % in Blue Nile
and South Kordofan States and 30% in the rest of the States. Furthermore, CSOs/NGOs
contribute significantly to the routine immunization services through static centers particularly in
Darfur, Blue Nile and South Kordofan states. Likewise, CSO/NGOs routine immunization mobile
clinic services cover considerable proportion of the targeted communities in Darfur States, Blue
Nile and South Kordofan States.
Local NGOs and CSOs are also engaged in raising community awareness on the importance
of immunization, refuting misconceptions and advocating for utilization of immunization
services. They play a critical role in creating bridges between international organizations
operating in rebel occupied areas and local communities.
Challenges faced by NGOs and CSOs include: weak coordination among themselves and
with national, state and local health authorities; limited capacity to mobilize volunteers to
provide immunization services; inadequate administrative and financial capacity to run regular
activities and to document & report performance.
Legal Policy and Regulatory Environment
The Sudan National Health Policy ,2007 , dealing with Child Welfare and Survival, states that
child health will be addressed through well-coordinated and integrated evidence based PHC
package both at facility and community levels, including; routine immunization, promotion of
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HSS Application Materials– 31/05/2013
breast feeding, provision of vitamin A supplements, newborn care and prevention and
treatment of common childhood illnesses, such as diarrhea, malaria and pneumonia ( Sudan
National Health Policy ,2007 policy statement number 8.2.4, page 16, Annex 7).
The Interim National Constitution of the Republic of Sudan, 2005 (Annex 8, Number 46, page
16), stipulates that States shall promote public health, establish rehabilitation, develop basic
medical and diagnostic institutions, provide free PHC and emergency services for all citizens.
The same document -in page 14, states that the State shall protect the rights of the child as
provided in the international and regional conventions ratified by the Sudan. The Child Act
2010, also clearly stated the rights of the children of Sudan for medical care, including
immunization.
Health and Community Systems financing
Total Health Expenditure in Sudan in 2009, amounted to approximately 6.0 % of GDP out of
which General Government Expenditure on Health was only 28.9% (NHA 2010, Annex 2) and
the rest was privately or donor funded. Only a relatively small amount out of the Sudan
national budget (9.6%) is spent on health and as a result out-of-pocket expenditure is very high
amounting to 64% (IHP+ 2012, 2010, Annex 9).
The way financial resources are currently transferred from Federal to lower administrative
structures for service delivery is very complex; funds are transferred from the Federal Ministry of
Finance and National Economy (MOFNE) either, 1) to FMOH and then to States Ministries of
Health, localities and to health facilities (family health Units, family health centers and rural and
urban hospitals) directly or 2) to State Ministries of Finance and then either directly to SMOH
and localities or through SMOH to localities and finally to health facilities.
Diagram of the financial flow
Ministry of Finance & National Economy
Federal Ministry of Health
State Ministry of
Finance
State Ministry of Health
Localities
Health Facilities
Such transfers represent 55% of those public funds spent on health care facility level. In addition
to government funding, health care facilities receive 9% and 5% funding from donors and
National Health Insurance Fund respectively (Gotsadze G.: A framework for equitable
distribution of health resources in Sudan. Technical Report, 2012) (Annex 10).
With regards to community health financing, there have been several initiatives in various
states and according to the 2010 Sudan NHA, the share of community financing from total
health expenditure was 0.03 %. However, in order to reduce the high out of pocket
expenditure (from 64% to 50%) the NHSSP, 2012-16 has emphasized the need for establishment
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HSS Application Materials– 31/05/2013
of community health financing and community based health insurance schemes (Annex 11).
Major issues of health care providers in delivering PHC services in the country are insufficient
salary levels and poor incentives, causing a high turnover and brain drain. To reduce this
negative impact, The FMOH in collaboration with development partners has developed and
endorsed a performance based incentive scheme to support programme managers and
service providers at all PHC levels. Mainly, GFATM and GAVI Alliance will be implementing this
scheme as of January 2014. This scheme will be shared with other development partners for
adoption and implementation.
TWO PAGES MAXIMUM
3. National Health Strategy and Joint Assessment of National
Health Strategy (JANS)
This section will be used to determine how immunisation is addressed in the
national health plan, and what the key findings of an independent JANS
assessment of the strategy were. The Independent Review Committee (IRC) will
use the findings of a JANS assessment to gain an understanding of the policy
and health sector context that will inform their assessment of the credibility and
feasibility of the HSS proposal.
→ Please provide a reference to the relevant sections and pages in the NHP
which outline immunisation policies, objectives, and activities.
→ If a Joint Assessment of the National Health Strategy (JANS) has been
conducted, please provide the JANS report as an attachment.
→ Please provide a summary of how the government and partners have
addressed the weaknesses and recommendations identified in the JANS or
attach the country’s response.
National Health Strategy
The 25-Year Strategic Plan of National MoH is explicit about the importance of immunization in
improving health outcomes. This strategic plan sets three objectives for the EPI namely: high
immunization coverage, achieving polio certification and maintaining polio free status, and
eliminating measles. The National Health Sector Strategy (NHSSP, 2012-16), emanating from the
25-year plan, also places great emphasis on improving immunization outcomes through
expansion and strengthening of primary health care.
The Strategic directions of the NHSSP, pertinent to EPI are; (i) Expanding and strengthening
primary health care (horizontally expanding the network and vertically by improving quality
and package of care), with the aim of improving equity in access and providing an
integrated, people-centred approach; and (ii) Implementing a defined minimum package,
with immunization as a key component, at all PHC delivery outlets including community service
delivery points (page 31). Expanding PHC/ immunization coverage is also highlighted in the
NHSSP strategic objectives and interventions (page 39) Table 5:
Log
Frame
for
each
Strategic Objective of NHSSP page 39)
The Sudan EPI Comprehensive Multi-Year plan, 2012-16 (EPI Comprehensive Multi-Year plan,
2012-16, Annex 12) which is aligned with the NHSSP has the following Objectives; (i) To ensure
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HSS Application Materials– 31/05/2013
equitable access for children, Women of Childbearing Age (WCBA) to existing and new
vaccines, and other interventions that lead to reduction of morbidity and mortality from
vaccine preventable diseases in Sudan; and (ii) To achieve at least 95% coverage for all
antigens and 70% coverage for WCBA with TT2+ coverage (page 33).
Joint Assessment of National Health Sector Strategy (JANS)
The NHSSP was developed through a long and participatory consultative process which
involved various partners and stakeholders at national and state level. It builds on an extensive
situation analysis and evidence from previous surveys and studies. The process also included a
comprehensive costing exercise using the ONEHEALTH Tool, to assess feasibility of the plan.
Sudan joined the International Health Partnership IHP+ in May 2011 to become the 51st
signatory of the Global Compact. The main objective for Sudan is to use the platform to
accelerate progress towards achieving MDGs by strengthening partnership for improved aid
effectiveness, as indicated in Paris Declaration, 2005 and Busan agreement, 2011. To date, a
lot of progress has been made- technical assistance was provided to develop the national
strategy and to improve the synergy between the sector and sub-sector strategies in addition
to the measures taken by different health partners to ensure harmonization and alignment of
their plans and interventions with the national health priorities through having One Plan, One
Budget and One Report. Currently FMOH and partners are finalizing the Operational Biennium
Plan, 2014-15.
A local Compact has been drafted and discussed with national and international partners.
Furthermore Sudan has participated in the 3rd round of the IHP+ monitoring process to track
progress in implementing aid effectiveness principles and targets.
Sudan organized a Joint Assessment (JANS) of its NHSSP in November 2012. The main objectives
of this exercise were to enhance and improve the quality of the strategy and ensure its
relevance and feasibility in the country context.
Sudan is the first country to use the “One JANS” approach in assessing its national health sector
strategic plan. This entailed the assessment of another four programme specific strategies (EPI,
HIV/AIDS, TB and Malaria) along with the national strategy. The country decided to go for a
One JANS for a number of reasons namely; to avoid risks of multiple JANS and related high
transaction costs and duplication; improve synergy between sector and programme strategies
(address fragmentation and inconsistency) and to institutionalize the JANS approach within the
planning cycle (strategy development and review).
The
JANS
mission
report
described
strengths,
weaknesses
and
provided
recommendations/suggested actions for each set of attributes (Annex 13) which were then
reviewed and addressed by a taskforce comprising FMOH staff and partners. Comments and
recommendations were then incorporated into the document. All recommendations were
accepted except one (see page 7 of the national response to JANS, Annex 14). Programme
specific strategies, including cMYP were updated to ensure synchronization and alignment
with NHSSP.
The final updated version of the strategy was endorsed in July 2013 (Annex 5). Sudan’s
experience in One JANS has been documented by IHP+ to draw lessons for other countries
(see link below)
http://www.internationalhealthpartnership.net/fileadmin/uploads/ihp/Documents/Results___Evi
dence/JANS_Lessons/Lessons%20from%20JANS%20in%20Sudan%20July%202013%20%20%20FINAL%20AUGUST%202013.pdf.
ONE PAGE MAXIMUM
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HSS Application Materials– 31/05/2013
4. Monitoring and Evaluation Plan for the National Health Plan
This section will provide background information on how the country organises
M&E arrangements and whether this proposal is aligned and complementary to
national M&E plans.
→ Please attach a copy of the M&E Plan for the national health plan.
→ Please provide a summary of how the National M&E Plan is implemented in
practice. In your answer refer to relevant sections of the M&E Plan in the national
health plan for further details.
→ Please provide a description of how development partners are involved in the
M&E of the national health plan implementation and financing. Is there a Joint
Annual Health Sector Review (JAR) and if so how and when are they are
conducted? Please outline the extent of GAVI involvement in the JAR process.
→ Is the immunisation programme review linked to the Joint Annual Review
(JAR)? Please state Yes/No.
The M&E framework for the current proposal is founded on the National Health Sector
Monitoring and Evaluation Strategy (National M&E Strategy, Annex 15) which was developed
based on IHP+ M&E Framework.
In line with the list of indicators in the M&E strategy, a comprehensive list of indicators was
drawn and ‘health system performance assessment’ review designed. This assessment includes
the review of the health system’s six building blocks and for the service delivery building block
in particular, the SARA methodology was used. Sudan’s first Health System’s Performance
Assessment (HSPA) was conducted during 2012-13 (Health System’s Performance Assessment
Report, Annex 16) which the M&E Department at MOH will institutionalize. This implies that the
national M&E system is evolving, and in this effort development partners are involved actively
in conceptualizing and designing the system.
UN agencies and bilateral partners are providing support to the implementation of national
health plan and to this effect, mechanisms are evolving to institutionalize a common MOH and
partners’ M&E framework and platform to jointly monitor the progress. In this regard, a partners’
forum has been established in MOH to bring together different partners, and a local compact
is being finalised to assure harmonization and complementarities of efforts for health
development.
In addition to the periodic reviews within the ministry of health at different levels i.e. individual
directorates (both at state and federal level and undersecretary meetings), reviews are held
between MOH and individual partners. Also, a joint state/federal review that is attended by
the state ministers and director general of health is held twice yearly. This bi-annual review,
following the direction in the NHSSP (page 66-67) is now being transformed to a Joint Annual
Review. In this regard, a team from MOH has participated in the JAR of Ethiopian MOH, and
technical assistance is being sought to define SOPs, guidelines and documents required for
conducting the JAR in 2014 (see attached JAR TORs, Annex 17).
In addition to tracking health indicators, FMOH is also tracking aid effectiveness indicators. In
this regard, in 2012, Sudan participated in the 3rd round of IHP+ monitoring process (Annex 9
Progress In The International Health Partnership & Related Initiatives (IHP+), 2012). Moreover aid
effectiveness indicators have been incorporated in the National M&E framework.
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HSS Application Materials– 31/05/2013
ONE PAGE MAXIMUM
5. Health
Outcomes
System
Bottlenecks
to
Achieving
Immunisation
This section will be used to understand the main bottlenecks affecting the health
system performance. The analysis here underpins the application, ensuring the
proposed activities are designed to address the bottlenecks.
→ Please describe key health and immunisation system bottlenecks at national,
sub-national and community levels preventing your country from improving
immunisation outcomes. Consider bottlenecks to providing services to specific
population groups, such as the under reached, marginalized or otherwise
disadvantaged populations. The country is also asked to consider gender related
barriers to accessing quality services.
In order to keep this section concise, please summarise the key elements in the
context of the HSS support being asked for, providing a reference to the relevant
section in the National Health Plan for further detail.
→ Please refer to bottlenecks which impact on gender and equity-related access
to immunisation.
→ Please reference the analytical work that led to identification of the
bottlenecks.
→ Describe the bottlenecks identified in any new vaccine proposals submitted to
GAVI, the National Health Plan, and any recent health sector assessments such
as the Effective Vaccine Management (EVM) assessment or Post Introduction
Evaluation (PIE).
→ Which of the above specified bottlenecks will be addressed by the current
proposal? Which bottlenecks are addressed by other national or externally
supported programmes?
In order to keep this section concise, please summarise the key bottlenecks and
provide references to the relevant sections in existing bottleneck analyses.
Please ensure the referenced analyses are provided as attachments.
Bottleneck Analysis
Review and analysis of the Sudan health systems bottlenecks was conducted in order to
identify EPI related bottlenecks preventing the country from achieving immunization outcomes.
The analysis was guided by the following strategic objectives as set out in the Sudan EPI
Comprehensive Multi Year Plan for Immunization (2012-16):
Strategic objectives:
 To achieve and sustain 95% coverage of the 3rd dose of pentavailant vaccine and 70%
for TT2+
 To increase and sustain penta 3 coverage by improving both equitable access and
utilization of immunization services as part of integrated PHC package in all district
 To maintain Sudan polio free status
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HSS Application Materials– 31/05/2013
To achieve and maintain measles elimination
To contribute to and maintain NNT elimination
To reduce morbidity and mortality caused by Rota virus, Niseria meningetdies and S.
Pneumonia and yellow fever
 To strengthen integrated surveillance system for VPDs/AEFI
 To strengthening programme managerial capacity
 To ensure sufficient fund for EPI activities
The EPI bottleneck analysis was complemented with a similar exercise by the three Global Fund
supported programmes namely HIV/AIDS, TB and Malaria, which employed the same
analytical tool (Global ATM bottleneck analysis, Annex 13). This joint exercise was intended to
provide a holistic view into the health system performance gaps and identify cross cutting
bottlenecks of the system. The UNICEF framework for bottleneck analysis was adapted for this
purpose (EPI bottleneck analysis using the adapted UNICEF framework, Annex 18) The
framework links strategic objectives, with corresponding intervention, activities and indicators.
Current situation of each activity was assessed and gaps in implementing strategic actions
were analyzed from the perspectives of supply and demand as well as quality and enabling
environment. Consequently, the identified bottlenecks were categorized into programmatic or
health system issues.



The analysis benefited from inputs of various stakeholders who convened in a consultative
workshop (GAVI/GFATM Health Systems Bottlenecks Consultation Workshop Report, 21
November, 2013, Annex 19) where programme- specific bottlenecks were presented and
discussed, which served as a bases for identifying cross cutting issues. Although the analysis
came up with bottlenecks at various levels, the proposal is intended to address those
challenges identified below. For bottlenecks which would be addressed by other partners,
please refer to Complementarity section of this proposal.
Summary of the main bottlenecks identified are described below:
Service Delivery
About 13.7% of the population do not have access to PHC services with a significant portion
being pastoralists, IDPs, communities with cultural/geographical barriers and/or living in conflict
affected areas. The overall DTP3 coverage among these groups (underserved and
disadvantaged populations) is 68.4%, however, there are great coverage variations within and
between states. 39% of the existing facilities are not fully functioning due to staff shortage or
poor physical infrastructure. Only 24% of health facilities provide the minimum package of PHC
services. Immunization is provided in 76% of all health facilities. Further, the various types of
health facilities are unevenly distributed in different states, i.e. there is a great variation in the
size of population served by a facility (For more details please refer to Annex 33). These
problems will impact on the Immunization Program, resulting in only 49% of immunizations being
delivered through fixed sites and 51% of the population covered through the outreach/mobile
strategy, with variation within and between states. Accordingly, the Reaching Every District
(RED) approach was introduced in 2002. However, the cost of the RED approach with regards
to logistics and transport has proved to be very high and unsustainable. The volatile security
situation of Darfur where non-functioning health facilities have led to the high dependence on
accelerated routine immunization activities that are dependent on availability of donor funds.
Vehicles available for implementing PHC including immunization activities (mainly mobile
session and supervision) at locality level are aging and experiencing frequent breakdowns that
resulted in poor implementation of planned activities.
Table below shows the distribution of the underserved/disadvantaged population and DTP3
coverage among them per state:
Underserved/disadvantaged groups
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HSS Application Materials– 31/05/2013
State
category
Northern
Pastoralists
River Nile
Pastoralists
Khartoum
IDPs
Red Sea
Kassala
Pastoralists, Refugees, Communities with
cultural/geographical barriers
Pastoralists, Refugees, Communities with
cultural barriers
Gadarif
Pastoralists, Agricultural camps
Gazera
Pastoralists, Agricultural camps
Sinnar
Blue Nile
White
Nile
North
Kordufan
South
Kordufan
North
Darfur
South
Darfur
East
Darfur
West
Darfur
Central
Darfur
Pastoralists, Communities with cultural/
geographical barriers
Conflict affected groups, Pastoralists,
Communities with cultural/ geographical
barriers
Pastoralists, Communities with geographical
barriers, Refugees
Conflict affected groups, Pastoralists,
Communities with cultural/ geographical
barriers
Conflict affected groups, Pastoralists,
Communities with geographical barriers
Conflict affected groups, Pastoralists,
Communities with geographical barriers
Conflict affected groups, Pastoralists,
Communities with geographical barriers
Conflict affected groups, Pastoralists,
Communities with geographical barriers
Conflict affected groups, Pastoralists,
Communities with geographical barriers
Conflict affected groups, Pastoralists,
Communities with geographical barriers
Total
Population
11,769
41,177
645,263
34,708
370,875
24,877
41,234
82,154
50,295
28,496
44,539
166,416
358,451
744,400
143,677
215,315
414,132
3,417,778
<1
year
DTP3 coverage among
these groups % (2012)
413
155
1445
84.4
22644
38.7
1218
62.1
13015
85.7
873
62.3
1447
47.6
2883
27.8
1765
88.9
1000
66.8
1563
73
5840
34
12579
111.9
26123
58.4
5042
112.1
7556
64.8
14533
84.5
1199
39
68.4
EPI and EVM Assessments were conducted in December, 2013 and revealed the vaccine
storage capacity was insufficient to cover the current and future needs in some states, also the
dry storage capacities were insufficient to meet the maximum demands. Some localities have
no passive containers and ice packs (some are very old and use Flynn boxes for vaccine
transport and some use ice blocks during vaccine transport and sessions in some health
facilities). In addition, there is no adequate vehicle transportation capacity for vaccine
delivery in some localities. There are no written maintenance plans/programmes for the
building/vehicles and refrigerates (state /localities/health facilities) (Annex 20-2).
Expanding EPI coverage in security compromised areas largely depended on limited hit- and26
HSS Application Materials– 31/05/2013
run or acceleration campaign approach which was facilitated by CSOs and NGOs operating
in such areas. However, the potential of local partners was not adequately utilized due to lack
of clear policy on engagement of CSOs/NGOs in PHC & community interventions particularly in
hard to reach areas, underserved and disadvantaged populations. High quality
Supplementary Immunization Activities (SIAs), were regularly implemented with donor support.
However, in order to maintain polio free status of the country, there is dire need for
government resource allocation and mobilizing community resources.
Since 2005 EPI has introduced several new vaccines according to the disease burden in Sudan.
These include Hepatitis B vaccine in 2005, DTP-HepB-Hib in 2008, Rota vaccine in 2011 and PCV
13 in 2013. External PIE was conducted for these vaccines which revealed that the introduction
process went smoothly and successfully with no major issues encountered a part from the
common EPI bottlenecks identified (HRH, storage capacity, transportation).
Effective advocacy and social mobilization at the community level are essential for increasing
demand and utilization of PHC, including immunization services. However, there is a lack of a
model for effective health promotion interventions at community level. There is weak
community participation in the planning and delivery of immunization services, which has a
negative implication on sustainability of provision of immunization services, as well as weak
community ownership.
Except Khartoum state, the private for-profit as well as not for profit health care is weakly
regulated and a policy for the private sector though developed, has not been implemented.
The private for profit that is growing very fast; focuses on curative services mainly and is
concentrated in urban areas.
With regards to gender, there is no information on the existence of gender based disparities in
accessing PHC/immunization services in Sudan which indicates the need for research in this
area. The study will be conducted to identify gender-related barriers in the national health
system, including in immunization services. The results of this research will be used to improve
the planning and implementation of interventions targeting different populations, particularly,
underserved and disadvantaged groups. Current HRH data shows that 67% of health care
providers are females, despite the geographic discrepancies. Moreover, volunteers providing
PHC/immunization services, including CHWs and village Midwives are predominantly females.
On the other hand, communication interventions are mainly targeting females while
observations have revealed that it is the males who often decide on access to health care.
Human resources for Health
In health, the career structure, incentives, regimen and mechanism for retention and equitable
deployment in rural, underserved and conflict and emergency prone areas are not well
developed. Health workers tend to move to the capitals or major cities in the states resulting in
nearly 70% of health workforce living in urban settings of which 38% are in Khartoum state,
serving only 30% of the population. The mal-distribution of health workers extends also to other
types of care, i.e. 33% of staff is employed in PHC settings, this resulted in considerable percent
of non functioning PHC facilities especially in rural areas, and it also compromises availability
and quality of PHC services. Also many health workers are pushed to the private sector and
migrate to other countries in search of better job opportunity, education, salaries and
incentive package.
Training is conducted regularly (basic and refresher) for existing and newly deployed staff.
However, high turnover of mid-level managers and over dependence on volunteer
vaccinators in EPI continues to be a challenge.
EPI is much affected by this situation, there is over dependence on volunteer vaccinators to
provide immunization services in most of the states. There is also shortage of cold chain
technicians at all levels.
Efforts have been exerted to promote evidence based Mid Level Management (MLM) by
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HSS Application Materials– 31/05/2013
providing training on operational research and problem solving approaches. However, rapid
turnover of MLM staff especially at locality level with its implications on services delivery and
need for more training activities are yet to be addressed. In addition to addressing shortage of
HRH at various levels, the quality of existing HRH also needs to be upgraded in certain areas.
The inadequate capacity of public health facilities to satisfy demand has led to more
dependency on outreach and mobile services. In order to overcome the limited access to the
hard -to- reach communities (14%) and those accessible health facilities that are not providing
EPI services (24%), PHC expansion will be implemented.
Health information
Health Management Information System (HMIS) is largely fragmented, due to the parallel
reporting structures and information sub-systems implemented by vertical disease specific
programmes including the EPI. There is low reporting rate particularly from PHC facilities and
the private sector. The information system is also characterized by poor quality of data with no
proper mechanism for data quality assurance and audit. There is lack of effective coordination
mechanisms with other sectors. The system is predominantly paper based with limited use of
information and communication technology. The data storage and retrieval capacity across
the health system is manual.
On the other hand, EPI information system had been relatively well established with
standardized recording and reporting tools and trained personnel deployed at all levels.
However, the EPI information system is designed vertical and heavily dependent on donor
resources. Utilization of data for programme management is limited only to federal and state
levels. The system also suffers from lack of community based information generation and
reporting mechanism, which could have supported the EPI in expanding services to hard- toreach communities.
At present, data and indicators for disease surveillance, including Vaccine Preventable
Diseases (VPDs), is collected by different departments in the MOH according to their
mandates. The data collected are solely based on clinical criteria. The current vertical
surveillance systems are characterized by significant under-reporting, delay and poor quality of
data, poor utilization of collected data, and lack of a proper feedback system.
EPI implements parallel surveillance systems for five of the VPDs in a fragmented and vertical
manner (even within the same program). Data are collected at different levels of the health
system, such as health centers, hospitals and community levels (AFP), which may be reported
to localities, state or federal levels. Different approaches of investigation and reporting tools
are used for each of the VPDs. The parallel EPI surveillance systems are not sustainable and
have high cost implications. At the same time the fragmented approach is hindering efforts
towards establishing/strengthening the national integrated surveillance system.
Despite availability of trained staff and standardized tools, data quality assessment or
supervision could not be conducted effectively. This is due to the lack of an integrated
approach to supervision and limited availability of logistics to meet the increased demand
created due to various vertical programs.
Governance
The weak organizational as well as individual capacity in policy analysis and implementation,
monitoring and evaluation, and lack of capacity to undertake robust policy processes across
the states' planning directorates, are prominent challenges.
Generally, the decentralized system is characterized by weak planning and management
capacities at sub-national level due to lack of appropriate, standardized structures and high
turnover of qualified staff. Only 50% of the localities have functioning health management
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HSS Application Materials– 31/05/2013
teams to perform its main functions (supervision and PSM).
There is lack of EPI policy and strategy in Emergency situations. Despite the regular microplanning exercise conducted by EPI, staff capacity is sub-optimal.
Health Financing
The allocation of public funding is very uneven across states. This disparity extends also to how
expenditure is incurred i.e. only 15% of the public health expenditure was on PHC and other
public health programs where allocation of funding is skewed towards curative care.
Government contribution to routine Immunization activities is limited to buildings and salaries
for permanent staff, injection supplies and co finance of the new vaccines as per GAVI
requirement. All other costs are donor funded.
High quality Supplementary Immunization Activities (SIAs), were regularly implemented with
donor support. However, in order to reach and maintain disease initiative targets of the
country, there is dire need for government resource allocation as well as mobilizing community
resources.
FOUR PAGES MAXIMUM
6. Lessons Learned and Past Experience
This description will highlight to GAVI how lesson-learning has been incorporated
into the design of the activities.
It will provide the evidence base that
demonstrates that the proposed activities will be effective, and that implementing
them will achieve the desired intermediate results and immunisation outcomes.
→ Please use the table in the proposal form to summarise the evidence base
and/or lessons learned related to each of the objectives in the proposal.
Applicants are asked to provide examples specific to their country of relevant
interventions that were successful.
→ In addition please provide examples illustrating the challenges to successful
implementation. If no evidence base exists within the country of question, please
note ‘not applicable’.
*Where possible, please provide evidence of this learning by providing a
reference or a web-link to a published document related to each example.
Objective
Example(s) of lessons learned, highlighting both
successes and challenges
Objective 1.
Good practice:
To
improve
sustainable
and
equitable
access
and utilization of
quality Immunization
as
part
of
an
Integrated Primary

Experiences from GAVI support revealed that expanding fixed
sites are cost effective and sustainable and therefore reducing
the high dependency on outreach and mobile services to
deliver immunization. The upcoming GAVI grant evaluation
(March 2014) is expected to provide additional evidence.

The micro-planning exercise supported by GAVI as part of RED
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HSS Application Materials– 31/05/2013
Health
Care
focusing
on
underserved
and
disadvantaged
population
approach, has greatly contributed to having an achievable
plan, rational management of resources and close monitoring of
implementation and target achievement in EPI.

Introduction of defaulter tracing system has been effective in
reducing drop-outs (EPI routine report).

Establishment of associations such as ‘Friends of Immunization’
,which involves NGOs, religious leaders, and the private sector at
state level, facilitated in addressing drop-out rates and missed
opportunities through creating demand and service utilization.

Health mapping exercise ( supported by GAVI HSS grant, 20082013), has improved the commitment of decision makers
towards PHC Universal Coverage by allocation of more
resources and ensuring equity and efficiency (Ministry of Finance
allocated additional US $13 million for PHC expansion) .

Improved government commitment, both political (a dedicated
week to celebrate immunization annually) and financial (has
progressively increased cost sharing and has contributed a sum
of $2.412 Million, in 2013 as a co-finance for the introduction of
new vaccines and cost of injection supplies, which
will
contribute to programme sustainability. In 2013, the government
had contributed a sum of $3 Million to the operational cost of
measles campaign.

Improvement in service delivery in GAVI target localities
positively influenced communities and policy makers in
neighbouring localities to avail resources for PHC/immunization
services (Gadarif State Ministry of health annual report 2012).

Harmonization and complementarity of GAVI and GFATM HSS
grants through joint management has improved synergy and
efficiency of resources utilization and avoiding duplication of
efforts.
Lessons learned:

Objective 2.
To strengthen an
integrated,
comprehensive,
efficient and
sustainable Health
Information System
in support of an
evidence-based
policy and planning
Although the EPI outreach and mobile strategies has enabled to
reach 51% of the target population, the approach has proved
expensive and unsustainable.
Good practice:
 Timely implementation of recommendations in assessment
reports (e.g. data quality assessment report) has improved EPI
information system that gained the trust of GAVI and other
donors in regard to the quality of reported data.
Lessons learnt:
 The poor coordination mechanism among different health
providers (health insurance & private sector) has resulted in
incomplete and deficient reports affecting decision making.
 The existence of vertical HIS (program specific), in addition to the
National HIS, resulted in poor quality of data which has been
manifested in under-reporting and discrepancy. These multiple
systems have overburdened the care providers due to the
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HSS Application Materials– 31/05/2013
Objective 3.
To support
production,
equitable
distribution and
retention of a multitasked facility and
community health
workforce to meet
immunization and
PHC needs
multiple reporting required.
Good practice:

Major issue in human resources management is insufficient salary
levels and poor incentives, causing a high turnover and brain
drain to other more financially rewarding posts. To reduce the
negative impact, the EPI has come up with a system of
incentives:




sponsoring post graduate training and short courses,
performance based incentive scheme financed through
GAVI was implemented to retain EPI Operation officers,
leadership training for state and locality health managers
training for mid-level management in the areas of
vaccine management, and planning issues.
These initiatives have contributed to the retention of EPI staff at national
and state levels as reflected in the relatively high coverage with EPI
services. (cMYP section 3.8.5, page 26).
Lessons learnt:
 The HRH operational research conducted under the previous
GAVI HSS Grant provided an insight into the HRH situation in
terms of identifying factors that would lead to their attraction
and retention. Efforts are still required to translate these results
into policy. (HRH gender, retention and migration research,
2013).
Initiatives related to the introduction into the system of CHW and
medical assistants and vaccinators to function as multi- task
health workers have been hampered by the limited capacities
of training institutions i.e. CPD and AHS and delay in provision of
equipment and medical supplies to deliver the services. Activities
related to this objective aim to address these challenges.
Good practice:
 The Regularity of supervision and auditing under GAVI HSS grant
made the state teams at GAVI target localities, committed to
implementation of their plans.
 Under previous GAVI grant states and locality managers were
trained in leadership and mangement. Effects/impacts of the
training program were reported to have contributed to improve
performance of managers (Evaluating the outcomes of
leadership and management programme report May, 2012).

Objective 4.
To strengthen
management and
leadership capacity
of the decentralized
health system at
state and locality
levels for an
effective and
efficient
implementation of
an integrated PHC
package including
EPI services
Lesson learned:
 Implementation of decentralized governance system was not
accompanied by clear policies to empower both states and
localities to exercise full power on resources including finance
(Annex 21, PHC expansion policy brief 2012).
 Poor working environment at locality level together with shortage
of qualified staff and dominance by vertical approach which
requires huge number of staff to meet the needs of all programs
resulted in poorly performing locality health management teams.
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HSS Application Materials– 31/05/2013
TWO PAGES MAXIMUM
PART D - PROPOSAL DETAILS
For further instructions, please refer to the Guidelines for
Completing the HSS Application
7. Objectives of the Proposal
This section will be used to assess whether the proposed objectives are relevant,
appropriate and aligned with the National Health Plan and cMYP, and contribute
to improving immunisation outcomes. It will also ensure alignment with the
bottleneck analysis above.
→ Please succinctly describe the immunisation and HSS objectives to be
addressed in this proposal and explain how they relate to, and contribute to,
reducing HSS and immunisation bottlenecks (identified in section C.5 above) and
strengthening of the health system. Please describe how these objectives are
aligned with those in the national health plan and cMYP.
The objectives need to be aligned to and numbered in the same way in the HSS
M&E Framework (Attachment 3) and also in the detailed Budget, Gap Analysis
and Workplan Template (Attachment 4).
For each objective, please describe:
a) Which immunisation outcomes will be improved by implementing the
activities, and how will the activities contribute to their improvement?
Please focus on the key activities related to each objective rather than
every single activity. Please demonstrate this link in the next section on the
results chain.
b) Whether and how the proposed objectives relate to the equity and gender
related barriers to access as identified in the bottleneck analysis, and how
the objectives will result in narrowing the equity gap in immunisation
coverage and contribute to reaching the under reached, underserved and
marginalised populations. Countries are requested to consider gender
related and geographic barriers to access of immunisation and other health
services.
→ Please list and describe all of the proposed activities in the Budget, Gap
Analysis and Workplan Template. If GAVI funding is requested to go into pooled
funds, please attach the Annual Work Plan and Budget for the pooled fund and
related TORs.
This description will be used to assess if the proposed key activities will be
32
HSS Application Materials– 31/05/2013
sufficient to achieve the identified immunisation outcomes.
The current proposal is basically founded on the overarching 25 years national Health strategic
plan, which is explicit on the importance of immunization and this was clearly stipulated in the
following three objectives: high immunization coverage, achieving polio certification and
maintaining polio free status, and eliminating measles. The proposal is in alignment with the
overall objectives and targets of the two live documents that are National Health Sector
Strategy (NHSSP- II) (section 1.3 page 2) and cMYP (section 4.3 page 32), which place great
emphasis on improving immunization outcomes through expansion and strengthening of
primary health care by ensuring equitable access for children, Women of Childbearing Age
(WCBA) to existing and new vaccines, and other interventions that lead to reduction of
morbidity and mortality from vaccine preventable diseases in Sudan.
Thorough HSS bottle neck analysis of the GAVI and GF-ATM supported programmes, provided
major inputs in the process of setting objectives for the grant application. Consequently, four
objectives were identified as priority HSS areas that are detrimental for the achievement of the
EPI and to the PHC expansion programme, which required appropriate interventions. The set
objectives are believed to facilitate achievement of the six EPI outcomes by complementing
HSS supports provided through other programmes including GFATM.
Objective 1;
To improve sustainable and equitable access and utilization of quality
Immunization services as part of an Integrated Primary Health Care focusing on underserved
and disadvantaged population
This objective aims at sustaining the current high coverage with EPI services in Sudan. The
Ministry's current move towards integration aims to guarantee efficiency and sustainability of
health services, including EPI services. This is very much in line with NHSSP which calls for
expansion of integrated PHC services which is aimed at increasing access and coverage with
health services.
Under this objective, special emphasis will be given to overcoming the limited access to
availing immunization services to underserved and hard to reach populations and conflict
affected areas as a result of the inadequate capacity of public health facilities to satisfy
demand, leading to high dependency on outreach and mobile services.
The planned activities are aimed at addressing this issue by gradually expanding the number
of fixed sites, rehabilitation of PHC facilities, provision of equipment and training of health care
providers in order to avail integrated PHC services at both health facility and community level,
and thus increasing the coverage with EPI services as well as improving both geographic and
socioeconomic equity in immunization coverage. Over dependence on volunteer vaccinators
in EPI will be addressed through supporting the AHS to increase the production of multipurpose
health workers to deliver quality integrated PHC services at both facility and community level
and thus improving the coverage with services, including immunization.
Moreover expanding the services will further be enhanced by engagement of CSOs/NGOs,
which have the capacity to deliver an agreed set of health care services for high risk or hardto-reach or with little health system contact including pastoralist. This approach will more
effectively serve the dire need of those population segments because they have ties to local
communities or experience of specific services, which enable them to scale up or intensify their
activities.
The situation analysis indicated that there is lack of evidence supporting existence of disparities
in service utilization due to gender gaps. In order to address this information gap, national
survey will be supported to assess the effect of gender in accessing and utilizing of health
services including PHC/immunization services.
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HSS Application Materials– 31/05/2013
In addition to availing the services other efforts will be made at improving quality through
implementation of guidelines, and training and supportive supervision of health care providers
to adhere to standard of practice including proper waste management. Besides,
Implementing Community-targeted Strategies to shift usage of healthcare towards PHC
utilization and Using existing community lay health workers (CHW) to advocate PHC to increase
uptake and acceptability by the community.
Objective 2: To strengthen an integrated, comprehensive, efficient and sustainable Health
Information System in support of an evidence-based policy and planning
This objective attempts to combat the current fragmentation and verticality of the national
health information system (HIS), towards an integrated system that would capture good quality
data from all levels, down to state and locality, in a timely and comprehensive manner. The
availability of such data would allow for developing policies and plans that are based on solid
evidence for strengthening the health system.
To this end, the proposed grant would facilitate the implementation of the National Plan for
strengthening and developing an Integrated Health Management Information System (HMIS)
as a continuation of previous efforts that have been exerted in that direction under the current
GAVI & GF ATM/ HSS grants.
The planned activities under this objective are geared towards integrating vertical programme
specific information systems within the national health information system, including EPI- HIS.
This step is crucial for the EPI programme as its sustainability is greatly jeopardized by its vertical
approach, being mainly dependent on donor support. Furthermore, separate EPI surveillance
systems will be merged and integrated with the national Disease surveillance system. This aims
at improving the detection and response to VPD outbreaks and health emergencies.
Institutional capacity building for an integrated HIS is central to this proposal where capacity
development of HIS managers, data producers and analysers shall be cared for in order to
ensure timely availability of reliable data for analysis and information generation which would
facilitate informed decision making. In addition, the routine data generation and reporting,
data quality assurance mechanisms will also gain focus.
Support would also be given to promissing initiatives such as the community Health Information
System (CHIS) as the huge gap in data availability at community level hinders proper planning
for the EPI programme that would support expanding and improving utilization of services to
hard to reach areas. The planned activities in this area aim to scale up CHIS by engagement
of CHWs and utilizing the available networks of Community Health Volenteers. Support of
integrated HIS and enhancement of CHIS is aimed at improved efficiency which will be
reflected in the decreased dropout rate between DTP1 and DTP3 coverage and increased
DTP3 and measles coverage.
Objective-3: To support production, equitable distribution and retention of a multi-tasked
facility and community health workforce to meet immunization and PHC needs
This objective has the purpose of scaling up the recent shift from monovalent to polyvalent
health workers so as to maximize the benefit of care providers in availing quality integrated
PHC services. This will be achieved through strengthening capacities of training institutions, with
special focus on state level, to improve the quality of training programmes. Efforts will also be
made to retain these health workers, especially posted in remote areas and hard to reach
areas.
Weak capacities of training institutions, especially at state level, limits the production of care
providers and quality of training. In order to improve the capacity of training institutions and
quality of training, the followig activities areplanned under the current grant: curricula review
of training institutions (AHS, CPDs and PHI) to be oriented towards PHC needs, including EPI;
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HSS Application Materials– 31/05/2013
develop/update training protocols, guidelines and materials; provide tution fees to AHS
students and rehabilitate and equip training institutions.
Huge turnover of specialized and midlevel health professionals and health managers within
and outside the country besides to the the preponderant shortage in allied health workers
(nurses, midwives and medical assistants) due to under production, has led to the maldistribution of the health workforce in rural, underserved and conflict and emergency prone
areas has negatively affected the coverage and quality of services, including immunization. To
address this issue, previous efforts will be pursued; evidence generated from the HRH research
on gender, retention and migration carried out under GAVI HSS grant, 2008-13 and
complimented by GFATM/HSS Grant, 2010-12 will be utilized to feed into the development and
implementation of an evidence based HRH Policy to guide decisions for appropriate strategies
to attract, retain and distribute human resources for health. Moreover, specific retention
measures (fellowships to vaccinators and other allied workers) will be taken aiming to address
the issue of high turnover of EPI mid-level management staff and its implications on services
delivery.
Furthering its efforts towards retention of HRH, the grant would also promote creating
conducive work environment by supporting states and localities authorities to conduct regular
HRH profile and inventory of essential commodities in their respective health services delivery
points to monitor existence of vacant posts or stock outs of commodities (and take timely
corrective majors). This approach would minimize burnout of staff usually associated to work
overload or frustration due to non availability of facilities but also builds confidence of
beneficiaries to use available services.
These activities will contribute to the production of skilled care providers and their retention
which will in turn increase access to health services, reduce drop-out rate between DPT and
DTP3 coverage and increase in DTP3 coverage and reduce geographic and socio economic
inequities.
Objective 4: To strengthen management and leadership capacity of the decentralized health
system at state and locality levels for an effective and efficient implementation of an
integrated PHC package including EPI services
This objective aims to strengthen the decentralized health system to ensure effective and
efficient management of service delivery which would in turn guarantee sustainability of the
services.
The planned activities under this objective intend to address the factors hampering
occurrences of essential changes required for strengthening the decentralized health system.
These factors include: the Inadequate allocation of resources at state and locality level for
health, frequent breakdown of vehicles hinder implementation of outreach services and
supervisory visits, limited capacity of locality in utilization of available resources for planning
and monitoring of services including EPI and weak engagement of CSOs/NGOs and under
implementation of social mobilization strategies at locality level due to limited financial support
and government commitment.
Solutions to address the above challenges are centred on creating and building capacities of
State and Locality Health Management Teams (S/LHMT) to meet shortfalls compromising
efficient health service delivery. Such solutions include: training in leadership and
management; introduction of integrated organizational structures, both at state and locality
level, aimed at improving performance and encouraging team work; availing zonal
coordinators who will play a critical role in strengthening SHMT that will in turn play their part in
building the capacities of localities as effective leadership will facilitate mobilization of
35
HSS Application Materials– 31/05/2013
resources and political commitment. Other solutions include: introduction and scale up of
supportive supervision, with the intention of maximizing utilization of available resources, and
building capacities in data utilization which would lead to better planning and monitoring.
Such interventions are presumed to increase local authority to implement results-based
management and to enforce local accountability for obtaining better service quality and
responsiveness, towards ensuring greater equity and improved health outcomes.
TWO PAGES MAXIMUM
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HSS Application Materials– 31/05/2013
8. Results Chain
This description will detail to GAVI how the proposed activities will result in improved immunisation outcomes.
→ Please present a Results Chain using the template provided in the application form for each objective. This diagram
should demonstrate how activities contribute to achieving outputs / intermediate results and how outputs/intermediate
results contribute to achieving immunisation outcomes. The outputs / intermediate results should link directly to the
HSS bottlenecks identified in Section 5 and should address or contribute to addressing the selected bottlenecks for the
GAVI HSS proposal.
(Please only include the key 4-5 activities for each objective that are central to delivery of intermediate results and
immunisation outcomes. It is not necessary to list all activities for each objective. The full list of activities should be
completed in the workplan and budget (see Section 10)).
→ The Results Chain should be consistent with the HSS M&E Framework. For every output / intermediate result and
immunisation outcome listed in the Results Chain there should be corresponding indicator(s) in the HSS M&E
Framework to measure achievement.
→ Please note that a GAVI HSS proposal must include the six immunisation outcome indicators listed in the Guidelines
Key Terms Section. Applicants are encouraged to include other immunisation outcome indicators as well which relate
specifically to the part of the health system where funds will be used.
→ Each result and outcome listed in the results chain should have a corresponding indicator in the Monitoring and
Evaluation Framework.
Objective 1: To improve sustainable and equitable access and utilization of quality immunization services as part of an
Integrated Primary Health Care focusing on underserved and disadvantaged population
Key Activities:
 Scale up the capacity of health care
providers to provide integrated PHC services
(at facility and community levels)
 Improve PHC facilities’ infrastructure to
provide integrated service packages
Outputs / Intermediate Results:
 Improved access to and utilization
of
PHC
services
including
immunization for underserved and
disadvantaged population
 Increased number of PHC facilities
Immunisation Outcomes:



Increased DTP3 coverage
Increased Measles coverage
Increased proportion of
children fully immunised
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HSS Application Materials– 31/05/2013
 Strengthen national EPI cold chain and
vaccine management capacity
 Support provision of outreach and mobile
services with focus on hard to reach and
disadvantaged populations
 Strengthen the PHC service provision, at
community
level
through
enhancing
partnerships with CSOs, NGOS and private
sector
 Design and implement a communication
strategy for community engagement and
demand creation especially for hard to
reach and disadvantaged communities
 Support medical waste management system
at health facility and community levels
providing
essential
package
including immunization, from 24% to
80%
 Enhanced CSO/NGOs engagement
in expanding immunization services
focusing
on
hard
to
reach
communities at 60 localities
 Enhanced national EPI cold chain
and
vaccine
management
capacity in all states (from 11 to 18)
 Improved adherence to guidelines
and SOPs at 90% of PHC facilities in
target states (6) with system quality
index of 80% or above





Decreased dropout rate
between DTP1 and DTP3
coverage
Improved geographical equity
in immunisation coverage
Improved socio economic
equity in immunisation
coverage
Increased access to essential
“PHC package”
Effective Vaccine Management
in place in 90% of the localities
Objective 2: To strengthen an integrated, comprehensive, efficient and sustainable Health Information System in support of
evidence-based policy and planning
Key Activities:





Strengthen HIS governance and
coordination capacity at state and locality
levels
Strengthen capacity of health workers in
M&E, surveillance, integrated HIS, and
operational research
Support roll-out of a web-based,
computerized HMIS and data quality
assurance system
Scale up community health information
system
Strengthen national capacity for registration
of vital events
Outputs / Intermediate Results:




Sustained number of health
facilities submitting timely, accurate
and complete EPI reports at 95%,
Increased number of PHC facilities
and community (public and
private) submitting regular
integrated reports (from 32% to
80%)
Strengthened/established
integrated surveillance system,
including VPD and AEFI in all
localities to meet the global
standard
Increased capacity for integrated
supportive supervision and data
an
Immunisation Outcomes:

Decreased dropout rate
between DTP1 and DTP3
coverage
 Improved geographical equity
in immunisation coverage

Improved detection and
response to VPD outbreaks and
health emergencies
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HSS Application Materials– 31/05/2013
quality monitoring at state level
Objective 3: To support production, equitable distribution and retention of a multi-tasked facility and community health workforce to
meet immunization and PHC needs
Key Activities:




Rehabilitate and equip training institutions to
increase production of skilled multi-tasked
allied health workers
Strengthening managerial/administrative
and teaching capacity of training institutions
Support development and
operationalization of national HRH retention
plan
Support implementation of HRH incentive
package
Outputs / Intermediate Results:



Increased number of PHC facilities
with the required number and
quality of staff according to
standard focusing on rural
areas(achieving 70% of PHC in six
target states)
Strengthened training institutions
(AHS and CPD) at target states to
produce sufficient and qualified
multi-tasked health workers (12
institutions in six states)
Increased retention of allied health
workers
Immunisation Outcomes:




Increased DTP3 coverage
Decreased dropout rate
between DTP1 and DTP3
coverage
Improved geographical equity
in immunisation coverage
Improved socio economic
equity in immunisation
coverage

Objective 4: To strengthen management and leadership capacity of the decentralized health system at state and locality levels for an
effective and efficient implementation of an integrated PHC package including EPI services
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HSS Application Materials– 31/05/2013
Key Activities:




Outputs / Intermediate Results:
Support operationalization of revised
organizational structures and job description
for states ministries of health and localities

Building management and leadership
capacities of zonal coordinators and locality
health management teams in integrated
PHC programme/service delivery and EPI
mid-level-management

Support implementation of regular
integrated supportive supervision at federal,
state ,locality and community levels
Scale up the capacity of EPI mid-level
managers

Increased number of localities
implementing the revised
organizational structure (from zero
to 60)
Increased number of localities with
functional health management
teams (from 92 to 152)
Increased proportion of locality
health management teams
conducting regular integrated
supervisory visits
Immunisation Outcomes:

Increased DTP3 coverage

Improved geographical equity
in immunisation coverage

Improved socio economic
equity in immunisation
coverage

Decentralized health system at
state and locality strengthened
and sustained
IMPACT: Please provide an impact statement and indicator(s)
impact statement



To contribute to the reduction of maternal and child morbidity, mortality and disability
To contribute to Measles and Neonatal Tetanus elimination and achieving and maintaining Polio-free status.
To contribute to the reduction of under-five morbidity and mortality caused by YF virus, Rota virus, S. Pneumoniae and N.
Meningitis.
Indicators for tracking these impacts are the following:






Neonatal mortality rate
Infant mortality rate
Under-five mortality rate
Maternal Mortality Ratio
Sustained absence of wild polio virus (WPV) transmission: Number of confirmed Polio cases reported
Incidence of Measles (confirmed cases per 1 million population)
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HSS Application Materials– 31/05/2013




Incidence of Neonatal Tetanus (NNT/1000 LB) in 81 High Risk Districts (HRDs) that have not yet eliminated NNT
Proportion of rotavirus gastroenteritis among reported gastroenteritis in under 5 yrs children
Proportion of Pneumococcal meningitis among reported bacterial meningitis in under 5 yrs children
Proportion of Nisseria meningitis among reported bacterial meningitis in under 5 yrs children
ASSUMPTIONS:



Timely disbursement of funds for implementation of project activities
Arrangements are in place in war affected areas to reach target populations with immunization services
Increased allocation of government resources for primary health care
THREE PAGES MAXIMUM
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HSS Application Materials– 31/05/2013
For further instructions, please refer to the Guidelines for
Completing the HSS Application
9. Monitoring & Evaluation Framework
This description will enable GAVI to assess how programme performance will be
monitored and to ensure alignment with National M&E arrangements. The
proposed M&E framework for the HSS grant should link to the proposed results
chain. While the Results Chain provides the rationale for how the proposed
activities will result in improved immunisation outcomes, this section provides
details of how the monitoring and evaluation will be undertaken.
→ Please provide an HSS grant Monitoring & Evaluation Framework as
Attachment 3 (please complete the GAVI template).
→ Please provide a description of how the monitoring and evaluation will be
carried out for the grant, indicating how M&E is aligned with the national health
plan results framework.
→ Which sources of data will be used?
→ How much budget will be allocated to M&E of this grant?
→ Please describe the M&E system strengthening activities to be funded through
this proposal.
→ Please identify one or more immunisation outcomes for each objective. These
will be used for PBF’s performance payment (see Figure 1 on page 7 of the
Guidelines)
→ Please identify a number of intermediate results indicators related to each
objective of the grant that shall be used for tracking the overall progress of the
grant implementation (these will be used for PBF’s programmable section (see
Figure 1 on page 7). These are the same intermediate results indicators that are
included in the Monitoring & Evaluation Framework, and will be used to measure
the outputs/intermediate results that are included in the results chain in Section
D.8.
Please note that GAVI strongly recommends that each proposal includes an end
of grant assessment in their M&E Framework.
The National Health Sector Strategic Plan (NHSSP), 2012-2016 and its M&E framework are
designed to address the shift from vertical disease/programme approach to an integrated
service delivery and monitoring of activities. The National M&E Plan was developed to enable
monitoring achievements towards attainment of the targets set forth in the NHSSP and covers
the same time period. The plan is based on the Results Chain and identifies a core set of
indicators and data sources, and describes plans for data collection and analysis, data quality
assessment, communication as well as dissemination of results. The plan aims to monitor the
resources invested, the activities implemented, services delivered, and to evaluate outcomes
and long-term impact.
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HSS Application Materials– 31/05/2013
Twenty seven (27) indicators, with data sources, baselines, annual targets and reporting
frequency are included in the ME& Framework of the NHSSP. These are a total of 5 input
indicators, 6 output indicators, 9 outcome indicators and 7 impact indicators. These core
indicators are tracer indicators that are reflective of the key priority areas of the NHSSP.
The implementation and M&E of the proposed GAVI/HSS Grant will be carried out as an
integral part of the National M&E plan. The National M&E Plan and the broader HIS will
ultimately be the basis for reporting on the results of HSS support provided through the grant.
Considering the time required for proper Integration to take place, the proposed grant will use
the existing EPI systems and structures to generate supplementary data and information
pertinent to the monitoring of key indicators that will not be captured by the overall Health
Information System (HIS).
Data Sources:
The National M&E Plan uses various complementary sources of data in order to generate
information on the key core indicators at the national and sub-national levels. These include:
 Health facility data - Includes both the routine health information system that is
collected at the health facility levels and periodic health facility surveys.
 Administrative data sources –encompass a wide variety of data sources such as;
financial data, human resources data, information on drugs/medicines and others.
 Regular supervision reports–reports from regular supervisory visits undertaken at various
levels i.e., Federal, State, Locality and community will be compiled and used to
compliment the other data sources.
 Civil registration/vital statistics (CRVS): Civil registration activities will generate vital
statistics and provide denominators that are crucial for monitoring program outcome
and impact at population level.
 Surveillance - The existing surveillance of VPD and AEFI, would provide crucial data
pertinent to EPI.
 Population-based surveys: Most of the impact and outcome indicators included in the
M&E Framework of the GAVI/HSS proposal are derived from population-based surveys,
making surveys a very important source of data for monitoring grant implementation
through establishing baselines and end-of grant evaluation.
The key planned
population-based surveys are the following:
o
o
o
o
Sudan Household Health Survey (SHHS): The country undertook two consecutive
SHHS surveys in 2006 & 2010 respectively that served as baseline for NHSSP and
the present proposal. According to the survey plan outlined in the National M&E
Plan, the third and fourth SHHS will be conducted in 2014 and 2018 respectively,
and will serve the purpose of monitoring progress as well as an end-of grant
evaluation for the GAVI/HSS grant. The SHHS may be harmonized with the MultiIndicator Cluster Survey (MICS).
EPI Coverage Survey: To be conducted every two years (2015 and 2018) using
the standard WHO EPI Coverage Survey method and tool.
National Health Accounts Survey: The first and second rounds of NHA were
conducted in 2008 (financed by GAVI) and 2012 (financed by GFATM/HSS)
respectively which provided baseline data with regards to availability of
resources and fund flow. Subsequent, planned NHAs would provide relevant up
to date data.
Effective Vaccine Management (EVM) Assessment: To be conducted in 2015 and
2017 using the EVM tool developed by WHO/UNICEF.
Allocated budget for M&E activities
A sum of USD 3,619,578.00 (12%) of the grant budget is allocated for M&E activities
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HSS Application Materials– 31/05/2013
M&E System Strengthening Activities:
The NHIS is undergoing a reform process for better management of integrated data at all levels
of the health system and services delivery. The effort, led by the government, is being
supported by development partners mainly GAVI and GFATM/HSS. Strengthening the M&E
system will be further enhanced through objective- 2 of current proposed grant i.e., “to
strengthen an integrated, comprehensive, efficient and sustainable HIS in support of an
evidence-based policy and planning”. Relevant activities in support of strengthening the M&E
are the following;
 Institutionalize routine systems for monitoring data quality, by conducting systematic
data quality assessment through health facility surveys:
 data quality assessment (DQA) desk review (using the WHO DQA tool),
 Service Availability and Readiness Assessment (SARA),
 Harmonize and align the National M&E Plan with the National HIS:
 Integrate immunization reporting within routine health facility reporting
systems,
 Align immunization programme reviews with the national annual health
sector review cycle (Joint Annual Review), and define establish
appropriate linkages,
 Support integrated disease surveillance and response (IDSR) system, including VPD and
AEFI;
 Improve reliability of national vital statistics, stratified by age and sex,
 Improve health facility reporting of cause of death (disaggregated by age and sex),
including vaccine preventable diseases,
 Improve the analytical content of EPI reviews as well as the immunization component in
SHHS/MICS,
Immunisation outcomes and intermediate results indicators, related to each objective of the
grant are provided below:
Objective1
To improve sustainable and equitable access and utilization of quality Immunization as part of
an Integrated Primary Health Care focusing on underserved and disadvantaged population
Immunization Outcomes
 Increased DTP3 coverage
 Increased Measles coverage
 Increased proportion of children fully immunised
 Decreased dropout rate between DTP1 and DTP3 coverage
 Improved geographical equity in immunisation coverage
 Improved socio economic equity in immunisation coverage
 Increased access to essential “PHC package”
 Effective Vaccine Management in place in 90% of the localities
Indicators for Intermediate Results
 percent of underserved/disadvantaged population covered by DTP3
 Percent of target population served by fixed immunization sites
 Percent of PHC facilities providing essential package including immunization
 Number of target health and community workers received training according to the
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HSS Application Materials– 31/05/2013
standards
 Number of localities with functional CSOs engaged in EPI activities
 Number of states that have cold chain functionality of 80% or more
 Percent of PHC facilities in target states with system quality index of 80% or above
Objective- 2
To strengthen an integrated, comprehensive, efficient and sustainable Health Information
System in support of an evidence-based policy and planning
Immunization Outcomes
 Decreased dropout rate between DTP1 and DTP3 coverage
 Improved geographical equity in immunisation coverage
Improved detection and response to VPD outbreaks and health emergencies
Indicators for Intermediate Results




Percent of health facilities that submit, accurate and complete EPI reports according to
standards
Percent of PHC facilities at target states submitting regular integrated reports according
to standards;
Percent of health facilities regularly submitting surveillance data on reportable diseases
including VPD and AEFI (integrated disease surveillance)
Number of states conducting data quality monitoring and shared reports (during the
quarter)
Objective 3
To support production, equitable distribution and retention of a multi-tasked facility and
community health workforce to meet immunization and PHC needs
Immunization Outcomes
 Increased DTP3 coverage
 Decreased dropout rate between DTP1 and DTP3 coverage
 Improved geographical equity in immunisation coverage
 Improved socio economic equity in immunisation coverage
Indicators for Intermediate Results
 Percent of PHC facilities (disaggregated by urban/rural) with the required number and
quality of staff according to standard at six target states
 Number of health training institutions graduating target number and quality of allied
health workforce at six target states
 Annual dropout rate of health managers at target states and localities
Objective 4
To strengthen management and leadership capacity of the decentralized health system at
state and locality levels for an effective and efficient implementation of an integrated PHC
package including EPI services
Immunization Outcome
 Increased DTP3 coverage
 Improved geographical equity in immunisation coverage
 Improved socio economic equity in immunisation coverage
 Decentralized health system at state and locality strengthened and sustained
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HSS Application Materials– 31/05/2013
Indicators for Intermediate Results
 Number of states and localities implementing the revised organizational structure
 Proportion of locality health management teams in six target states conducting regular
integrated supervisory visits
 Number of localities with functional health management teams
TWO PAGES MAXIMUMTWO PAGES MAXIMUM
10. The Proposal Development Process
This section will give an overview of the process of proposal development,
outlining contributions from key stakeholders.
→ Address all the items listed below. Indicate if any of these are not applicable
and explain why:
a. The main entity which led the proposal development and coordination of
inputs. It is possible to have multiple lead implementers, however the country
must decide which department will lead the proposal development process.
The proposal development process was led and coordinated by the Directorate General of
Planning and International Health based on its mandate to oversee health system
strengthening issues.
b. The roles of HSCC and ICC.
The National Health Sector Coordination Committee (NHSCC) was originally established to
co-ordinate HSS programme activities funded by GAVI, later on with the upcoming of GF
and with the intension of harmonizing HSS funding it was reorganized to include members of
the CCM and was renamed " National Health Sector Coordination Committee/Sub-CCM
(NHSCC/CCM HSS Sub-Committee )". Recently, the Inter-Agency Coordinating Committee
(ICC) that oversees the GAVI ISS programme and co-ordinates the work of agencies and
donors who are supporting immunization and vaccination programmes, has been
integrated within the existing NHSCC/Sub CCM (TORs for NHSCC/CCM HSS Sub-Committee,
Annex 22). This new structure aims to insure that GAVI HSS initiatives are directed towards
strengthening EPI programme and thus improving the coverage and accessibility of
immunization services in Sudan.
The Committee is chaired by the Undersecretary of the FMOH and includes representatives
from the Federal Ministry of Health, Ministry of Finance, Ministry of Interior, Ministry of
Defence,
development partners such as UNDP, UNICEF, WHO, Rotary and NonGovernmental Organisations (NGOs) working in health (Sudanese Red Crescent , Plan
Sudan).
c. Cooperation between EPI programme and the other departments of MOH
involved in the proposal development.
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HSS Application Materials– 31/05/2013
A Steering and technical committees were formulated on 03, November, 2013 for the
development of GAVI HSS and GF new applications
(Undersecretary Decrees for Formulation of Technical Committees for Development of new
applications for GAVI and GF, Annex 23). The Technical Committee, headed by the
Director of Planning and Co-chaired by the EPI Manager, provided a platform for
involvement and participation of all relevant FMOH departments and partners through
weekly meetings, was mandated to carry out the following:
- Prepare operational plans for proposal development process
- Nominate sub-committees to draft the proposal
- Update the Steering Committee through regular meetings
- Finalize the proposal and obtain approval from the Steering Committee
A Drafting Committee was assigned for the drafting of the proposal. In addition to
participating in Technical Committee meeting, the EPI Programme played a central role in
the proposal development process through participation in the Drafting Committee. This
Committee met on daily basis for incorporating inputs and drafting of the document.
d. Involvement of subnational level (provincial, district, etc.) entities.
The Directors of Planning from two states, Khartoum and Gadarif (one of GAVI HSS previous
target states), participated in the bottleneck Analysis Workshop conducted on 21
November, 2013 (GAVI/GFATM Health Systems Bottlenecks Consultation Workshop Report,
21 November, 2013, Annex 24) to identify cross cutting issues for GAVI HSS and GF ATM and
to gain insight into issues of concern to lower levels.
e. The role of CSOs in the proposal development. Applicants must describe
whether the HSCC/ICC worked with any CSO platforms/coalitions, or just with
individual organisations. Please provide the names of the specific CSOs or of
the CSO platforms involved.
CSOs Representative was a member of the Technical Committee and participated in the
(health systems bottleneck analysis workshop conducted on 21 November, 2013
GAVI/GFATM (Health Systems Bottlenecks Consultation Workshop Report, 21 November,
2013, Annex 24) A meeting was held with CSOs Representatives for orientation on GAVI
funding, achievements made under the previous grant and the Ministry's attempt for the
new application. The meet was also aimed to insight into the role of CSOs and their
involvement in provision of immunization and other PHC services as well as identifying the
challenges. Other several meetings were held with the CSOs Representative at which
activities that will be implemented by CSOs were communicated and agreed upon,
including funding modalities.
CSOs involved, include the following:
- Martyr Majzoub Charity organization
- World Vision Sudan
- Sudanese Family Planning Association
- Sudanese Red Crescent Society Care Association
- Marriage Foundation (MFPD)
- Global Health Foundation (GIIF)
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HSS Application Materials– 31/05/2013
-
Federal Humanitarian Aid Commission (FHAC)
Sudanese Health Emergency Foundation
Islamic Agency
Patients Support Fund
Al Manar Voluntary Organization
El Zubeir Charity Organization
Ana Assudan organization
Durar Elryan Organization
Gadia Omom organization
Rufaida Health Foundation
Volunteers Everywhere Foundation
Sudan Development Association
Sanad Charity Foundation
Patients Helping Fund
f. The names and roles of other specific development partners/donors.
Refer to (h) below
g. The role of the private sector, if applicable.
The private sector is represented in NHSCC/CCM HSS Sub-Committee. The representative
contributed in reviewing as well as in the endorsement of the document.
h. Description of technical assistance received during the proposal development.
Include the source of technical assistance and a comment on the quality and
usefulness of that technical assistance.
Source
Assistance Provided
WHO
Drafting of M&E section for situation analysis
 Supported the adaptation process of developing
the framework used to identify the HSS bottlenecks
for GAVI and GF programmes.
 Bottleneck analysis exercise for GAVI/GF
 Contribution in drafting of the following sections of
the proposal:
o Situation analysis
o Results Chain
o Sustainability
o Risks and mitigation measures
o Technical assistance required for
implementation
o Work plan and budget narrative
 Provided inputs and review of the whole proposal
 Development of M&E framework
 Drafting of M&E narrative section
UNFPA
UNDP
Quality and
Usefulness
Good quality
and useful
Good quality
and useful
Good quality
and useful
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HSS Application Materials– 31/05/2013

UNICEF




CSOs/N
GOs


Contribution to drafting of national health sector
strategy and results chain
Contribution to the drafting of procurement section
Cold chain and vaccine forecasting and costing
Participation in bottleneck analysis exercise
Reviewing draft document; SA, result chain and
M&E.
Held workshop for the constituency to reflect on
their role in proposal development &
implementation and sharing best
practices/innovative approaches in support of
PHC/immunization service expansion
CSOs/NGOs Participated in the preparation of SA,
HSS-bottleneck analysis
Good quality
and useful
i. Description of the overall process of proposal development: duration, main
steps of the proposal development, analytical work involved in the proposal
development, links between the proposal development and national health
sector planning/budgeting, links between the proposal development and JANS
(if applicable).
Preparations for development of the proposal began as early as November 2012 when
a ONE JANS was conducted for EPI, Malaria, HIV/AIDS and TB programmes alongside
the JANS for the National Health Sector Strategic Plan. This exercise was carried out
taking into account all future applications, in order to achieve alignment with the
strategy and complementarily between different grants. Furthermore, The ONE JANS
provided guidance to the proposal development process, in particular making use of
the recommendations to update the cMYP. The development of the GAVI HSS proposal
lasted till 23rd January, 2014.
Main steps of the proposal development:
 Plan of Action (POA) for the new HSS application was drafted (Annex 25)
 A letter of intent for the new application was submitted to GAVI Secretariat on
02, October, 2013.
 A meeting of NHSCC/ CCM HSS Sub-Committee on 27, October, 2013 (NHSCC/
CCM HSS Sub- Committee Meeting, Annex 24) to agree on the methodology and
plan of action.
 A Steering, Technical and Drafting Committees were formulated to lead and
develop the proposal (details provided in "C" above).
 A comprehensive situation analysis was prepared, followed by a Health systems'
bottleneck analysis exercise for the four programmes (EPI, Malaria, TB, HIVAIDS)
prepared by the Technical Committees. This was presented at a workshop for
FMOH departments and partners, attended by GAVI and GF joint mission, on 21
November, 2013. The purpose of this exercise was to identify the cross-cutting
health systems bottlenecks which will assist in achieving complementarily
between health systems strengthening projects (GAVI, GF ATM, EU) in addressing
the identified bottlenecks.
 A meeting was held with CSOs on 20, November, 2013 to discuss the challenges
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HSS Application Materials– 31/05/2013






related to their current involvement in PHC service provision, including
immunization and to ensure their effective participation in the proposal
development process and implementation of grant activities. Two working
groups were formulated at this meeting. The first group was assigned to identify
activities, geographical locations and best practices related to CSOs while the
second group to identify bottlenecks and challenges related to CSOs
participation.
Alongside the drafting of the proposal, the EPI Programme updated cMYP, 201216 based on the JANS recommendations, ensuring alignment with the national
health strategy. EPI Review and EVM were conducted from 1 to 21, December,
2013. The recommendations arising from the assessments fed into the developing
the proposal.
Two joint missions (GAVI/WHO and GAVI/GFATM) were organized prior to and
during the proposal development process. These missions were directed towards
advocating for the New Funding Model and sensitization of partners.
Three call conferences were held, namely with GAVI Secretariat, WHO EMRO
and joint WHO EMRO & Headquarters. These have been very useful in providing
guidance and responding to national quires.
The draft proposal was submitted to WHO Regional (EMRO) and Headquarters for
review on 4th January, 2014. The comments, inputs and recommendations were
received on 12th January, 2014. These were reviewed and incorporated in the
proposal.
The proposal was finalized and endorsed by the NHSCC/CCM HSS SubCommittee on 21st, January, 2014 (Annex 24 GAVI HSS New Application
Endorsement Meeting, ppt and minutes).
The proposal was submitted to GAVI secretariat on January 24th 2014. WHO HQ
conducted a pre-review of the documents on January 27 – 31, 2014. The
comments and recommendations were received on February 1st. These have
been reviewed and addressed by the national team (please refer to national
response to WHO pre-review comments and recommendations in Annex 35).
j. Description of the most challenging elements during the proposal
development and how they were resolved.
The greatest challenge faced in developing the proposal was meeting the deadline for
submission by the end of December 31, 2013 in order to make it for February IRC
Meeting. Meeting that deadline was crucial so as to avoid a funding gap that was likely
to occur between the current grant and the proposed one if the proposal was delayed
for the following IRC meeting that was due in May, 2014. This was overcome by the
participatory approach that was adopted, involving all related departments and
partners in drafting and providing inputs to the different sections of the proposal, based
on relevance. Frequent follow up on progress and reporting, dedicated drafting group
and TA facilitated in filing out the different sections of the proposal according to plan.
The drafting committee has spent over 660 working hours preparing the proposal.
Approach to involvement of CSOs was also challenging since the constituency is not
well organized. Key persons were granted membership to TC who communicated with
other organizations and assisted in identification of relevant organizations, meetings and
participation.
•
LESSONS LEARNT
One JANS was very useful in guiding the process
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HSS Application Materials– 31/05/2013
•
•
•
•
•
Alignment and harmonization (Complementarity between GAVI, GFATM and other
partners) at planning stage will facilitate the implementation
Effective partnership and involvement of all partners has created confidence and
ownership of the process
National leadership and participation of all relevant FMOH departments has led to
ownership and capacity building in fund raising.
Good and active involvement of CSOs/NGOs enriched the proposal and established a
platform between FMOH and CSOs.
Experience/lessons learned will contribute to GFATM concept note development
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PART E – BUDGET, GAP ANALYSIS AND WORKPLAN
11. Detailed Budget and Workplan Narrative
This description will be used to assess if the proposed budget shows sufficient
justification for the proposed activities and activity costs within the HSS grant.
→ Please provide a detailed budget and work plan as Attachment 4 to this
proposal. Please refer to the Guidelines for the list of items required from the
budget and work plan. It is highly recommended that applicants use the GAVI
HSS Budget, Gap Analysis and Work plan template as Attachment 4. However,
countries can also provide this information in the format of an existing national
Annual Operational Plan or equivalent document.
→ Please include additional information on the assumptions within the budget
and justification of unit costs to demonstrate that they are reasonable and
supported by in-country planning. These assumptions and unit cost justifications
may be inserted here or attached as separate documentation.
The proposal is envisaged to be implemented over a period of five years (2014 – 2018), with
proposed budget of USD 33,240,000.00. The project will be managed by PMU-Directorate of
Planning and International Health. The key implementers are EPI, Federal departments
(Planning, HMIS, HRH, M&E), States' Ministries of Health in target states, and Locality health
offices, Health training institutions and NGOs/CBOs. Accountability matrix on the roles and
responsibilities of partners will be developed.
Inputs, assumptions and unit cost
The inputs for the GAVI HSS grant are Training, Labour, Civil work, Commodities, Vehicles,
Printing and Events. Description of each input is as follows:
Training- is the major input of the grant. Training activities involve basic, in-service and
fellowships that take place at various levels for various durations. Assumptions vary accordingly.
a. With regards to in-service training the assumptions are DSA for participants, facilitators,
meals and refreshments, stationeries and venue. Number of participants for each
session on the average is thirty, while the duration of each training session is determined
based on national standards.
b. In the case of basic training, tuition fees, travel cost, books and stationeries, and living
expenses and incidentals. The duration of each training session is determined based on
national standards.
c. Fellowship costing assumptions are course fees, travel cost and living expenses and
incidentals. The duration of training for each course is estimated based on experience
and the available information from commonly used national and regional training
institutions.
The overall basis for the assumptions in cost estimation for the three training categories
identified above is the experience from GFATM current grant which was developed on
evidence base and after continuous consultation and negotiations with partners including
UNDP.
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HSS Application Materials– 31/05/2013
Labour Unit- The activities are mainly concerning hiring consultants for technical assistance to
support capacity building of government/partners and enhance project implementation. The
TA recruitment involves National consultants or internationals supported by nationals. The logic
behind having international consultants coupled with nationals is to facilitate skill transfer to
nationals so as to build pool of national experts in those areas of specialties for future use in a
sustainable manner.
Unit TAs rates was based on UN rates applied in Sudan. Assumptions for unit costs for TA
include fees, DSA, travel expenses and endorsement/consultative or dissemination workshops.
Civil work - includes rehabilitation/upgrading of Family Health Centers and Units to meet up to
the national standard. The unit price is calculated mainly follows the standard procedures;
based on competitive bidding process as regulated by the National Procurement Act 2010.
Commodities (medical and cold-chain equipment, IT equipment, skill labs and teaching Aids):
A national standard exists with list and specifications of commodities and corresponding unit
price developed by Health technology Department. For example the unit price for cold chain
equipment is based on UNICEF global agreed price. With regards to the IT equipment and
others, unit cost estimate is based on current experience from GFATM and Multi Donor Trust
Fund.
Vehicles: The updated rate is used by GFATM in putting estimated cost for the procurement of
vehicles.
Printing: The assumption of estimated cost is based on current experience that puts in to
consideration volume/quantity, quality, size, and number of pages of the material.
Accordingly, unit cost set are one, five and twenty USD depending on the above factors. The
process will follow national competitive bidding process according to the national guidelines.
Events: In view of the complexity of detailing such costs, these activities are broadly
categorized to meetings, supervisory activities, surveys, and reviews. The assumptions and unit
costs are based on the national UNDP/GFATM experiences and rates.
Major expenditure items
Item
Budget
USD
Capital
7,724,000.00
investment
in
infrastructure
Transportation
Improving
quality of care
Demand
generation
Scaling-up
of
health
work
5,282,000.0
5,167,650.00
3,401,590.0
2,901,685.00
Additional information/Remark
Addressing improved access by poor, underserved and
disadvantaged populations.
The budget will compliment government and other
partners' efforts to implement PHC universal health
coverage plan. Government of Sudan has committed to
support the PHC universal coverage Plan by $ 65 million
which constitutes 49 % of the total budget of this plan
($132.8 million).
This will ensure continuity of service utilization and
reduction of drop-outs/defaulter rates
Addressing barriers for service utilization including gender
and socio-cultural barriers
Would promote improved quality of services and
upgrade current PHC services in an integrated manner.
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HSS Application Materials– 31/05/2013
force
(health
professionals)
Routine
M&E
HMIS, 1,848,700.00
Thus, improving accessibility of services. The budget will
compliment government and other partners' efforts to
implement PHC universal health coverage plan.
To strengthen integrated health information system as
one of the national HSS priorities. This will complement
GFATM support.
Human Resource cost- is based on national incentive package scheme which will be
implemented to pay state and localities EPI/PHC focal persons. This scheme is being used by
government and GFATM as a measure to retain qualified human resource for health as high
staff turnover, particularly midlevel health professionals, is one of the main HSS bottlenecks.
The government and partners are jointly exploring means and ways to address the issue of
sustainability. Such majors include; developing National Health Finance policy which GAVI has
supported its preparatory work (NHA survey); GFATM is supporting PHC costing and
institutionalization of NHA and increase in government budget allocation for health from 9.8%
to 15% (Abuja declaration) by 2016. In addition, expansion of the national health insurance
scheme would contribute to redistribution of some of the resources to support PHC services.
Proposed HRH cost
1. States and localities PHC/EPI focal persons (18 states and 184 locality focal persons).
2. Five Zonal advisors/coordinators
3. Project management staff
The total estimated budget for the HRH activities is USD 1,435,200.00
Notice: additional detailed work plan with activity breakdown and cost assumptions will
annexed
TWO PAGES MAXIMUM
12. Gap Analysis & Complementarity
This description will ensure GAVI is aware of support provided by other donors,
thereby avoiding overlap or duplication, and highlighting the value-added of the
requested GAVI support.
→ Please complete a gap analysis that is related to each of the GAVI HSS
proposal objectives. The gap analysis should use information as available in
National Health Sector Strategy/Plan, cMYP, or other gap analysis conducted, to
show the total resource requirements for health systems strengthening related to
each of the proposal objectives. Applicants are encouraged to use the GAVI HSS
Budget, Gap Analysis and Workplan Template but can chose an existing country
template.
→ For each of the objectives, applicants should list different resources for HSS
financing already in place that contribute to the proposal objective, including
government and external donor contributions, the project name if applicable (or
indicate budget support), duration of support, funding amount provided (in US$),
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HSS Application Materials– 31/05/2013
and geographic location covered by the support. The guidelines provide more
detail on the key required elements of the gap analysis.
→ In the box below, please provide a narrative description of other efforts by the
Government or development partners that focus on the bottlenecks that are
addressed by the proposal objectives, including the timeframe and the
geographic location of this support, thereby highlighting the value-added of GAVI
support and how the current proposal complements those efforts.
GAVI encourages the use of data from existing gap analyses, rather than
undertaking a new gap analysis.
With regard to the main EPI partners, these include, the government/MOH, WHO, UNICEF and
some major NGOs. The Government is mainly responsible for payment of the permanent EPI
staff at all levels (National, state, District, health unit), and supporting the programme with
infrastructure, transportation and other logistical issues. Ever since the starting of GAVI support
in 2002, the government of Sudan has progressively increased cost sharing and since 2006 it
took over the cost of injection supply for traditional vaccines, and since 2008 co-financed the
cost of pentavalent vaccine, Rota since 2011, PCV 13 since 2013, and expressed commitment
to co-finance the introduction of Mening A conjugate and Yellow Fever vaccines.
Partners provide technical and financial support to the programme for routine services as well
as for the supplementary immunization activities. WHO’s support includes deployment of
international and national experts at different locations and co-coordinators at both federal
and state levels. WHO further supports the AFP surveillance network, NIDs for polio eradication,
training, and other routine and supplementary activities. UNICEF provides vaccines bundled
with AD syringes and safety boxes for routine and campaign use. The Fund further supports
polio NIDs, as well as MNT and other routine EPI activities (e.g. social mobilization and cold
chain).
The EPI received GAVI ISS support since 2002 -2010. GAVI support was used for routine activities
and it supported the phased introduction of new hepatitis B vaccine starting in 2005 and
DTP_HepB-Hib in 2008 as well.
As for Health System Strengthening, the main partners beside government are GFATM, GAVI,
WHO, MDTF and EU. The government is responsible mainly for HRH salaries and contribute to
provision of health services at primary and other levels of health care with more focus on
curative care (secondary and tertiary levels). Public funding has risen considerably in recent
years and reached 9.8% of public expenditure in 2011. However, it did not reach the 15%
agreed by African Ministers of Health in the Abuja Declaration.
Following the endorsement of the National Health Sector Strategic Plan 2012 – 2016, the
federal government of Sudan has committed to support the PHC universal coverage Plan by $
65 million which constitutes 49 % of the total budget of this plan ($132.8 million). PHC UHC plan
is aiming at provision of basic PHC services for the 14% of the population who do not have
access to any kind of health services. Furthermore, this plan targets up-grading of PHC services
in 76% of the existing facilities which are not providing the Integrated Basic Package of PHC
Services.
Development Partners provide technical and financial support to address health system
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bottlenecks to improve the outcomes of different programme specific interventions; to
mitigate the risks and sustain the results. The Global Fund ATM has provided support to HSS
since 2010 for 5 years with a total budget of $18 million. The support includes improving the
referral system from primary to other levels of health care; strengthening the Integrated Health
Information System; support scaling-up of training of health workforce; support strengthening
and up-grading of the Integrated Procurement and Supply Management System; support
strengthening the capacity of the Decentralized Health System and building up health system
financing capacity. The current HSS GFATM grant will end in February 2015. Currently, the
country is preparing a concept note under GFATM new funding model for the period 2015-17.
GAVI HSS grant covered the period from 2009 – 2013 with a total budget of $16.15 million. GAVI
support is focusing on the following areas:

Strengthen/build core systems and capacities (organization and management; health
planning and development, health financing; health management information system
and monitoring and evaluation)

Develop health human resources and strengthen the capacity of MOH to produces,
deploy and retain PHC workers focusing on nurses, midwifes, lab technician and
multipurpose health workers;

Contribute to achieving 90% EPI coverage in all 15 Northern states; and

Contribute to achieving 75% equitable coverage and access to quality PHC services
necessary for improved maternal health and child survival in the 4 targeted states.
GFATM and GAVI HSS grants are used together in a harmonized way to address the health
system bottlenecks. The two grants are complementing each other in terms of geographical
coverage and programmatic areas. Some of activities are being implemented nationwide
and some others are implemented in target states. GAVI has focused on four states (Gadarif,
Sinnar, White Nile and North Kordofan) while GFATM is covering four states (Northern, River Nile,
Gazera, Khartoum). The remaining five states were covered by MDTF which ended in June
2013.
The European Union agreed to support HSS project in the Eastern States (Red Sea, Gadarif and
Kassala) with a total budget of EUR 16 million. The overall objective of this project is to
contribute to improved health status and welfare of the served communities through effective
delivery of basic health services, improving its quality and increasing its utilization in the target
states. This project will start in 2014 and continue for three years.
In Darfur region with its five states (North, South, East, West and Central), the health services
were severely affected by the conflict resulted in further weakening of the already weak,
inefficient, ineffective and inequitable health system. Following the recent Doha Peace
Agreement, the government of Sudan together with the partners organized a Joint Assessment
Mission (D-JAM) to study the humanitarian, recovery and development needs of the region.
Based on the results of D-JAM, the Federal Ministry of Health developed A Health and Nutrition
Recovery Strategy for Darfur 2012 – 2016 (Health and Nutrition Recovery Strategy for Darfur,
2012 – 2016 Annex 26).
The main drivers for the strategy are:
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HSS Application Materials– 31/05/2013

Increasing access to health and nutrition services by removing/lowering the existing
barriers and enhancing service appeal to users, and boosting quality of care and the
range of offered services.

Alleviating the health financing burden of households, particularly of the poorest
ones.

Overhauling skills and appropriateness of health workers, hiring them in a timely
fashion and managing them productively.

Reducing service delivery costs by taking efficiency-oriented measures and improve
management, particularly at locality level.
The costed strategy has been approved in Doha conference which took place in April 2013.
The donors led by Qatar and the government of Sudan are committed to fund the strategy
with a total budget of $255 million.
WHO and other UN agencies are providing technical assistance in different health system
building blocks according to the national priorities and the joint biennium plans.
UNFPA in pursuit of its global strategic targets of improving maternal and newborn health is
supporting HSS through its regular and humanitarian response unit. HSS supports include:
training of midwives both basic and in-service; renovation and equipping health training
institutions, warehouses and health facilities (operation theatres and obstetric fistula
management centers), strengthening health commodities procurement and Supply system
and its integration with national system, HMIS including harmonization of RH/MNH data with
routine institutionalization of Maternal Death Surveillance and response system (MDSR).
The Federal Ministry of Health together with partners have started the preparation of the
concept note for GFATM New Funding Model. The process is done jointly for GAVI and GFATM
new applications to ensure harmonization and complimentarity from the planning phase. Both
applications are contributing to the implementation of the National Health Sector Strategic
Plan (2012-16) with more focus on supporting improvement of access to Basic Integrated PHC
Services for vulnerable and disadvantaged population; strengthen the Integrated Health
Information and Surveillance Systems; up-grade and strengthen procurement and supply
system and building the capacity of the Decentralized Health System.
TWO PAGES MAXIMUM
13. Sustainability
This description will enable GAVI to assess whether issues of sustainability have
been adequately addressed.
→ Please describe how the government is going to ensure sustainability of the
results achieved by the GAVI grant after its completion. This should encompass
sustainability of financing for immunisation services and health system
strengthening, as well as programmatic sustainability of results.
→ If there are other recurrent costs included in this proposal please describe how
the country will cover these costs after the funding finishes.
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Sustainability and selecting high impact interventions were well considered during the
development of this proposal. Sustainability has been addressed in several aspects as
following:
Financial sustainability: In this grant, GAVI will continue support efforts to develop the national
financial policy and strategy. The policy will address issues related to improving revenue
generation; decreasing fragmentation of schemes and enhance pooling; and identify options
for moving towards strategic purchasing. Support will be provided to institutionalize the
national health account at federal and states levels. Also a study will be conducted for
resource mapping and to explore the financing options to ensure sustainability of PHC services
including the gains of vaccination. The NHSSP 2012 – 2016 aims at increasing the total
government expenditure on health from 9% to 15% as stated in Abuja Declaration.
Available evidence from the National Health Accounts 2008 revealed that the current pattern
of resources utilization is inefficient. More than 80% of the resources are spent on hospital care
while PHC services are receiving less than 20% of the total health expenditure. Redressing
inefficiencies - both technical and allocative - will be one of the main directions during the
course of the proposed grant period. The MOH will work to assure efficiency by allocating a
higher share of resources to PHC and cost-effective interventions. The strategic vision is to
move from the current level of spending, which is less than 20% of the Total Health Expenditure
(THE) on PHC and public health programs, to reach about 40% investment in PHC by the end
of the 5 year health strategy. This has been materialized in the current PHC Universal Coverage
Project which is primarily supported by the government.
FMOH will look broadly across its programs and work with partners both at national and state
level, to discover new and innovative ways to collaborate and use resources wisely and
efficiently, taking advantage of multiple disciplines and shared knowledge and promoting
holistic approaches to health protection. In the M&E framework there is an outcome indicator
to track the local (domestic) financial allocation to PHC including immunization.
According to the results of existing national health and health related surveys and assumptions
made based on the costing exercise of NHSSP, 2012-16, if the country's economic situation and
its expenditure on health did not change so much during the plan period, the MoH has to
exert more efforts with the National Ministry of Finance (NMoF), UNICEF, WHO and other
potential partners in order to secure sufficient resources for the implementation of the PHC/EPI
as part and parcel of the cMYP and NHSSP 2012-2016.
Programmatic Sustainability: According to the strategic directions of the NHSSP, the FMOH will
introduce new investment areas to ensure an integrated programmatic and services delivery
approaches. As part of its efforts to foster integration throughout the health system, the FMOH
will promote the delivery of PHC Essential Service Package and adopt a unified approach for
monitoring and supervision of service delivery. Such an approach is intended to improve
effectiveness of PHC coverage and quality of services and at the same time promote
efficiency and cost reduction by side-stepping vertical programmes which proved resource
intensive and hard to scale up or sustain.
At present, the Ministry of Health is taking practical measures like, development of national
standards for essential integrated services packages for different levels of care; integrated
health information system registration and reporting tools, and availing the necessary logistics
for sustained provision of the required services in an integrated manner. Essential and
appropriate technologies based on standard list and specifications for different levels of
service provision will be used in the procurement of medical and cold chain equipments. The
grant will support capacity development of management and maintenance of assets and
equipments.
Allocation of human resources is also critical to ensure that states with the worst health status
can attract and retain trained health workers. On this regards, training will continue to be
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given to allied health workers and managers on integrated management and service
provision with the aim to produce multi-task health professionals to maximize the benefit of the
available HRH. This proposal is supporting moving from dependence on volunteers in service
provision (for some services) to Community Health Workers who are more sustainable and
accountable to the health system. In the previous HSS grant, GAVI has contributed to conduct
HRH Gender, Migration and Retention Research. In this new grant, support will be provided to
develop and implement HRH retention policy.
Political Sustainability: In the previous HSS grant, GAVI has supported PHC mapping survey. The
results of this mapping were used as evidence to advocate for PHC Universal Coverage Plan
among the political and community leader to ensure and sustain their commitment. In this
grant support will be provided to organize policy dialogues for policy and decision makers in
selected topics. Moreover strengthening decentralized health system will capacitate states
and localities to advocate and lobby for health agenda particularly for resource mobilization
and political commitment. Existing and emerging global and national coordination
machineries, such as the Local compact, CCM and others would be adhered to, in order to
realize the agreed upon ground rules set forth to ensure aid effectiveness through enhanced
government leadership, alignment of programmes to national priorities, harmonizing resources
and reporting. The MOH and partners are currently finalizing the local Compact. This will serve
as a platform for alignment and harmonization, and predictability & sustainability of support.
Social and community sustainability: In this grant, several interventions are targeting
generating demands and increasing and sustaining utilization of PHC including immunization
services among targeted communities. Selected interventions and approaches in service
provision will be sensitive to the local community cultural values. For example gender of health
provider (vaccinator) will be considered according to the local acceptance by the served
communities.
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PART F – IMPLEMENTATION ARRANGEMENTS AND RISK
MITIGATION
For further instructions, please refer to the Guidelines for
Completing the HSS Application
14. Implementation Arrangements
This section will be used to determine if the necessary arrangements and
responsibilities for management, coordination, and technical assistance inputs of
the implementing parties have been put in place to ensure that programme
activities will be implemented.
Please describe:
→ How the grant implementation will be managed. Identify key implementing
entities and their responsibilities with regard to specific grant activities.
→ Mechanisms which will ensure coordination among the implementing entities.
→ Financial resources from the grant proceeds that will be allocated to grant
management and implementation.
→ The role of development partners in supporting the country in grant
implementation.
The proposal is designed to fit within the overall national health sector development objective,
which is to contribute to achieving NHSS 2012-2016 and cMYP PHC/Immunization objectives:
The proposed fund will contribute towards strengthening the national health system to be
responsive to the dire health needs of the population of Sudan. Some of the activities will be
implemented nationwide and others will be implemented with more focus on target six states
namely; Sinnar, Blue Nile, River Nile, North Kordofan, West Kordofan, and South Kordofan with
an estimated total population of 9,818,370 (24.5%). EPI related interventions will cover all states.
Focus interventions include infrastructure, HRH production and strengthening decentralized
health system. Selection of the states is to ensure complimentarity and to avoid duplication of
efforts by other partners, taking in to consideration their comparative advantages, and also to
ensure equity in access. Annex (33) is describing the key interventions per state.
Northern State, Khartoum and Gazira States will receive funds to sustain the current relatively
high level of EPI coverage. Other states have secured grants to support PHC expansion
including EPI. These states include the Eastern States (Gadarif, Red Sea and Kassala) which
receive support from the "Eastern Fund" provided by the Kuwaiti Government and will be
receiving an HSS grant, worth $19,000,000 in 2014 from the European Commission. Other states
that receive special grants (the Darfur Fund) are the Darfur states (North, South, West, East and
Central) provided by the Arab League and bilateral, in addition to an emergency fund such as
CHF.
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At national level GAVI HSS grant will be coordinated through the following existing structures for
GAVI and GFATM Health Systems Strengthening Grants:

NHSCC/ CCM HSS Sub-committee

GAVI/GFATM Health systems Strengthening Project Management Unit

Grant Implementation Team
NHSCC/ CCM HSS Sub-committee
The NHSCC committee comprising FMOH staff, representatives from development partners
and non-government organizations was previously formed within the national health system to
co-ordinate HSS programme activities funded by GAVI, later on this was merged with ICC to
ensure harmonization in planning, implementation and monitoring of HSS and immunization
activities supported by GFATM and GAVI and renamed "NHSCC/CCM HSS Sub-committee".
This arrangement was made with the intension of aligning activities and harmonizing HSS
funding. This new structure, additionally, aims to ensure that GAVI HSS initiatives are directed
towards strengthening EPI programme and thus improving the coverage and access to quality
immunization services in Sudan.
The principal role of the NHSCC/CCM HSS Sub-committee is to provide oversight and
coordination and discuss critical issues affecting the implementation of GAVI/GFATM HSS
programmes. The committee meets regularly, twice a year and convenes extraordinary
meetings when deemed necessary for example in the case of reprogramming or any other
major issues that need urgent decision. During the annual meetings Annual Progress Reports
and plans are reviewed and endorsed before submission to GAVI.
GAVI/GFATM Health systems Strengthening Project Management Unit
The Sudan Federal Ministry of Health (FMOH) through the GAVI/GFATM Health Systems
Strengthening Project Management Unit (PMU), integrated within the Directorate General of
International Health DGIH, will continue the management of GAVI HSS grant, as with previous
grants. The unit includes the following members (HSS Project Management Unit Organizational
Structure, Annex 20). The PMU state focal points are coordinating grant implementation and
monitoring at state/locality levels. Moreover, they also coordinate regular review meetings with
stakeholders including CSOs/NGOs overseeing and facilitating project implementation.
The PMU is accountable to the Undersecretary of FMOH and NHSCC/CCM HSS Sub-committee
to which it submits performance reports and seeks guidance. This unit carries out the day to
day management of both GAVI and GFATM HSS grants and meets on weekly basis for an
update on progress.
Grant Implementation Team
HSS grant activities are implemented by the Grant Implementation Team which comprises
focal points from the relevant FMOH programmes/departments implementing HSS activities.
The PMU has the responsibility of following up on implementation of activities with these focal
points at federal level as well as focal points at state level (Planning Directors). The Grant
Implementation Team holds bi-monthly meetings (or more frequent on a need basis) with the
respective Directorates of FMoH, GAVI & GF focal points (including EPI), as well as
Development Partners for GAVI & GF (such as UNICEF, UNDP, WHO). Topics requiring a decision
to be taken are then raised to the NHSCC/CCM HSS Sub-committee.
With regards to partners role in support of EPI; in addition to their representation in the
NHSCC/CCM HSS Sub-committee, a National Immunization Technical Advisory Group exists,
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which meets 2-3 times per year, where representatives from UNICEF, WHO, Paediatric
associations, and other partners discuss and addressing the evidence based decisions required
in relation to New Vaccines Introduction and weekly surveillance meetings.
Role of CSOs/NGOs
The MOH is now considering working with CSOs and NGOs as part of its efforts to expand
access to immunization services in hard to reach areas, where these partners have
comparative advantage of being present in the community. In this regard, the PMU will be
working in close collaboration and coordination with the CSOs and NGOs to ensure effective
and efficient utilization of the grant. The CSOs/NGOs will play a key role in implementation of
interventions targeting community mobilization and provision of services to hard to reach and
disadvantaged population such as outreach activities targeting pastoralists/nomads and IDPs.
Several consultation meetings were held with CSOs/NGOs during the preparation of this
proposal to agree on how to involve this constituency in planning and implementation of GAVI
HSS grant. There is a consensus among NGOs to establish networks at sub-national levels to
improve their implementation capacity. In the first year the application to implement GAVI
supported activities will be on individual bases (NGOs will apply separately), but starting from
second year the implementation will be through the established net works. For the first and
second year of the grant, funds will be channelled to CSOs through the ministry of health, while
constraints in doing so will be addressed on individual basis. As for the third year, funds will also
be released through the MoH while capacities will be built for the newly formed networks, with
special focus on financial management, which are expected to have adequate capacity to
receive direct funds from GAVI from the fourth year onwards. Transfer of funds will be done
through comprehensive and close monitoring system.
Role of Academia
Some activities will be implemented in collaboration with the national academic institutions
e.g. researches and surveys. Social and gender centres such as Ahfad University for Women will
contribute to the implementation of the study on gender-related barriers in Sudan Health
System including immunization services.
Implementation Modalities
Different implementation modalities will be used for the different contexts and scenarios. In
normal circumstances where there is stability, FMOH will use its existing structures. On the other
hand, in states and localities where there is emergency and humanitarian situation, services will
be provided through locally existing structures by contracting CSOs/NGOs as set out in the
national health policy. This will be taken into consideration in State and locality health
planning. CSOs/NGOs have rich experience in reaching vulnerable populations and
underserved groups. Approaches may include, outreach, mobile services or a
pulse/acceleration plans. Where appropriate, plans will be developed for the transition from
emergency to development support.
Grant Management
Financial resources from the grant proceeds which will be allocated to grant management
and implementation amount to $1,595,190 and are intended to provide support to DGIH to
carry out annual planning, M&E activities, TA to support implementation, capacity building of
staff, payment of performance based incentives to PMU members and to state and locality
staff implementing GAVI activities, annual external audit, support M&E activities at state and
locality level, and end of project evaluation.
Grant monitoring and End of Grant Evaluation
Implementation of the grant will be monitored in line with the national M&E framework. The
following tools will be used:
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 Regular meetings of the Grant Implementation Team
 Periodic meetings with states and localities and CSOs
 Regular supervisory visits to the states and localities
 Periodic reporting by implementers
 Annual and periodic reviews
 Assessments and surveys
There will be an End of Grant Evaluation in 2018.
Grant start date
The Grant start date is May, 2014. This has been chosen for the following reasons:
-
FMA has been conducted in 2012 and according to the aide memoire and
guidelines, the next one will be conducted in 2015. Therefore step six of the
application process will be skipped and this will shorten the time lag between
approval and fund disbursement.
-
Available funds for EPI programme will be sufficient up to April, 2014. Fund
disbursement in May, 2014 is crucial to avoid immunization services interruption.
Preparations to start the implementation in May 2014 will be initiated early (in March) to ensure
that the country will be ready for implementation in May. These include starting the bidding
process for procurement (quantities, specifications, approval of methods of procurement);
selection of participants for different training activities (prepare lists of participants); preparing
detailed implementation arrangements and operational plans and sensitizing the
implementers particularly at states level.
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15. Involvement of CSOs
This description will be used to assess the involvement of CSOs in
implementation of the proposed activities. CSOs can receive GAVI funding
through GAVI HSS grants going to the MoH and then transferred to the CSO2.
→ Please describe how CSOs will be involved in the implementation of the grant
activities, indicating the approximate budget allocated to CSOs.
→ Please ensure that any CSO implementation details are reflected within the
detailed budget and workplan.
CSOs play a complimentary role in supporting PHC services in general and the Immunization
programme in particular. The range of PHC services supported by CSOs varies with regard to
geographical locations, both at community and facility level. Capacities for service delivery
outlets (Family Health Units (FHUs) and Family Health Centers (FHCs) through which PHC
interventions, including immunization of children and mothers, are delivered also vary. At
community level, they have networks of volunteers who mainly participate in outreach and
supplementary immunization activities, in addition to their involvement in community
2
In special circumstances grant funds can go directly from GAVI to a CSO, please refer to the Application Guidelines for further information.
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awareness and surveys.
There is great interest among CSOs in establishing well structured networks by 2014, based on
shared concerns, with the aim of effective implementation of activities, resource mobilization,
as well as efficient use of resources. These networks as planned, will have constitutional
arrangements which will be selected based on an agreed upon criteria, with which each a
memorandum of understanding will be signed, and assessed for identifying the appropriate
modality for channelling GAVI HSS funds. For the first year of the grant, funds will be
channelled to CSOs through the ministry of health, while constraints in doing so will be
addressed on individual basis. As for the second year, funds will also be released through the
MoH while capacities will be built for the newly formed networks, with special focus on
financial management, which are expected to have adequate capacity to receive direct
funds from GAVI from the third year onwards. Transfer of funds will be done through
comprehensive and close monitoring system.
Based on the planned arrangements, the current proposal identified major supportive activities
with regards to enhancing trustworthy relationships including: a) creating better policy
environment for accountability and harmonizing plans, monitoring and reporting, developing
code of conduct that would keep partners to adhere to standard of practice, b) capacity
building in the areas of project management and value for money, and c) scaling up of
community based CSO initiatives such as "friends of immunization".
Encouraged by their potential in advocacy and behavioural change of communities towards
self- assertiveness and health seeking behaviour, CSOs/NGOs would be encouraged to deliver
PHC/EPI services with focus to outreach and mobile services in areas where PHC facilities do
not render comprehensive integrated services. It is envisaged that strengthened CSOs/NGOs
partnership with the public system would make stride in expanding PHC services for the
disadvantaged rural communities residing in geographically inaccessible areas including hard
to reach and conflict affected areas. This will also open opportunity to reduce equity/access
gaps as a result of socio-economic and gender disparities.
key activities and budget related to CSOs/NGOs in grant implementation include:

TA for mapping and assessment of the capacity and engagement of CSOs/NGOs
and the private sector in PHC service delivery including EPI (2 nationals) - estimated
budget 15,050 US $.

Scale-up community initiatives and networks such as "friends of immunization" to
promote utilization of PHC services and minimize drop-outs (EPI, TB, HIV) - estimated
budget 153,660 US $.

Conduct integrated outreach services focusing on underserved localities with low
EPI coverage - estimated budget 77,700 US $.

Conduct integrated mobile services focusing on hard to reach and underserved
communities with low EPI coverage (meetings, joint missions) twice a year in federal
and the six target states.
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16. Technical Assistance
This description will outline to GAVI how technical assistance will support
implementation of the proposed activities.
→ Please describe technical assistance (consultancy services) included in the
grant activities. Please describe how this technical assistance will improve the
way health systems and immunisation programme function.
→ Please outline how technical assistance will improve institutional capacities of
government agencies and CSOs and contribute to sustainability.
The GAVI-HSS project technical assistance intends to complement the Government of Sudan's
ongoing efforts to strengthen health systems through provision of institutional and individual
capacities to improve the quality of health care and health outcomes. The expectation is that
the granted fund would be used to fill in identified HSS capacity gaps and thereby contribute
to increased access to appropriate, high-quality PHC, especially for the most vulnerable
populations & health outcomes and encourage individuals to adopt behaviours that will
improve their health.
Evidence gathered to date indicates that, the health system faces huge capacity gap at
policy, managerial, programmatic and service delivery levels which necessitate technical
support. Bottleneck analysis results proposed the need for a range of international and national
experts in short term and medium term to provide practical policy directions as well as help
introduction/scaling up of quality managerial skills of integrated health programmes and
service delivery.
The proposed grant, providing technical support aims to: 1) develop/strengthen the existing
PHC quality of care policy framework, 2) develop a strategic plan and guidelines and
standards for an integrated PHC services 3) to facilitate development, deployment and
retention of HRH, 4) develop policy briefs and plans to strengthen decentralized health system
management and 5) provide technical support to ensure effective and efficient management
of GAVI project. As a complementary activity, the fund will provide technical support for the
development of a policy and code of conduct to promote public, CSO/NGOs and private
partnership and roles in improving access to and utilization of integrated PHC /immunization
services.
Key Technical Assistance Activities (For more details please refer to the TA plan, Annex 34)
a) Partnership for PHC service provision; review policy and design a comprehensive
framework of partnership to enhance meaningful engagement of CSO/NGOs and
private sector in PHC and community mobilization.
b) Quality of care; Develop national guidelines and standard of practice on an integrated
PHC service provision including medical waste management; and Monitor progress on
implementation of integrated people-centred approach (draw lessons, document
experiences, suggest corrective measures).
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c) Availability of Quality data and reliable information: to develop national HIS
organizational structure and recommend key institutional capacity development
activities in order to establish harmonized and integrated HIS and HMIS and community
health information system; to support development/up-date of integrated disease
surveillance and response system including VPD and AEFI; to review legal framework for
registration of vital statistics events & design and pilot digital birth and deaths
registration; and support the development of national and state health profiles.
d) Availability of multi-tasked skilled and motivated human institutions: to support
development of educational programme responsive to an integrated PHC services and
needs and its implementation; and to develop policy brief and retention plan for
human resource for health.
e) Strong and functional decentralized governance of health services to improve
integrated PHC services provision: to adapt the document on organizational structures
and job descriptions for states ministries of health and localities; to develop/up-date
national integrated PHC services and immunization sustainability plans; and to
develop/up-date planning manual and tools for states and localities. Last but not the
least;
f) Enhance project implementation: to provide long term technical assistance by hiring
zonal coordinators to support group of states organized under zonal arrangement. At
the same time this will give an opportunity for capacity building of staff.
The total budget allocated for Technical assistance is $1,125,304. In conclusion, the proposed
fund will provide technical assistance and support to: the Program staff and partners for the
implementation of the PHC expansion plan for improved access to quality PHC/immunization
services; and to communities to improve access and create demand for and utilization of
PHC/integrated services.
The fund will also support complementary sectors and institutions providing technical expertise
such as technical training, quality assurance, community strengthening and mobilization skills,
etc.
The above support will likely strengthen the PHC management and quality of care in facility
and community service delivery points and indicate progress.
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17. Risks and Mitigation Measures
This information reflects the risk of a country not being able to
implement the proposed activities within this grant proposal and/or
spend the funds as approved by GAVI. It is expected that the Lead
Implementer will be responsible for assessing and ensuring that
risk mitigation measures are actually implemented.
→ If the country has existing health sector risk analysis please
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attach these assessments and provide here a brief reference to
the relevant sections.
→ If the country does not have existing health sector risk
analysis, please complete the table below for each of the
proposed objectives. Please refer to the Guidelines for
Completing the HSS Application for a description of the various
types of risk. If the risk is categorised as ‘high’, please provide an
explanation as to why it is ‘high’.
Description of risk
PROBABILITY
IMPACT
(high, medium,
low)
(high,
medium,
low)
Mitigation Measures
Objective 1: To improve sustainable and equitable access and utilization of quality
Immunization services as part of an Integrated Primary Health Care focusing on underserved
and disadvantaged population
Fiduciary Risks:
Possibility that funds (cash) are
lost due to fraud, corruption, or
theft by implementers including
CSO/NGOs
Low
Possibility of un anticipated
Medium
financial losses due to foreign
exchange, price or other market
changes
Medium
Possibility of GAVI assets
(noncash) are lost due to theft
or diversion
Delay in fund transfer from GAVI
to FMOH and from FMOH to
state/locality
Low
Medium
Medium
Conduct capacity gap assessment
(financial and management) of
CSO/NGOs
applying
for
GAVI
funding
through
government.
Capacity building based on findings
DGIH
(GAVI/GF
HSS
Project
Management Unit) will ensure that
pending advances are reviewed
and retired on a weekly basis.
FMOH is implementing a long term
plan to strengthen the capacity of
the financial system at federal and
state levels. This plan was developed
following the FMA conducted by
GAVI in 2012 and the financial
assessments
conducted
by
GFATM/UNDP
2012/2013,
the
recommendations
of
these
assessments
were
addressed.
Technical assistance provided by
GFATM/UNDP to support FMOH in
improving the financial system. A
training workshop, facilitated by
international
consultant,
was
organized in December 2013 for the
financial and programme staff from
federal and states MOH.
DGIH
(GAVI/GF
HSS
Project
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HSS Application Materials– 31/05/2013
Management Unit)
will ensure that strict controls at the
central level are applied at the state
levels regarding cash transfers, petty
cash
management
and
the
management of cash advances.
DGHI will receive funds in Euro bank
account and keep it in hard currency
and release requested amount in
SDG based on quarterly basis
according to planned activities for
implementation.
Institutional Risks:
Possibility that funds budgeted
cannot be used due to limited
absorptive capacity
Operational Risks:
Possibility of the grant not
achieving its Output
performance targets
Low
Low
medium
Medium
MOH with partners (mainly UNDP/GF)
are currently developing asset
management system that includes
regular asset verification
Improve the reporting and timely
submission of reports and responses
to clarifications to GAVI through
regular training of financial and PMU
staff.
Strengthen the capacity of the
finance management units at states
through training and back up.
Building the capacity of all states in
Financial & accounting system by
providing on the job training to both
managers and junior finance staff.
Proper internal auditing system and
regular review of internal processes
during supervisory visits.
Building the capacity of all states in
Financial & accounting system by
providing on the job training to both
managers and finance staff and
CSO/NGOs.
Detailed operational plans will be
developed according to national
and states biennium plans to guide
the implementation of the grant.
PMU will be strengthened by
recruiting additional staff as well as
capacity building to effectively
manage grant implementation.
The grant was developed based on
evidence and founded on NHSSP
2012 – 2016 and cMYP which were
subjected to One JANS.
NHSCC was merged with ICC to
ensure harmonized monitoring of
implementation
of
HSS
and
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HSS Application Materials– 31/05/2013
immunization activities in line with
GAVI FMA recommendations.
PMU will be strengthened by
recruiting additional staff as well as
capacity building to effectively
manage grant implementation.
Overall Risk Rating for Objective Low
Medium
1
Objective 2: To strengthen an integrated, comprehensive, efficient and sustainable Health
Information System in support of an evidence-based policy and planning
Fiduciary Risks:
Possibility that funded assets (noncash) are lost due to theft
Low
medium
Institutional Risks:
Fragmentation and vertical
approach of HMIS leading to
Inadequate monitoring and
evaluation activities, and poor
data quality,
Medium
Medium
Operational Risks: CSOs/NGOS
and private sector not submitting
regular HMIS reports
Medium
Medium
A national unified asset
management system is currently
under establishment to manage
asset including regular asset
verification.
MOH and partners have undertaken
several mitigation measures to
address this issue, which include
revised national HIS strategy, NHSSP,
2012, cMYP. This will be further
enhanced through the following:
 Support the implementation of
the integrated HMIS for improved
monitoring
 Institutionalise a routine data
quality assurance mechanism
 Build capacity at all levels for
analysis and use of data
 Develop a fully costed M&E plan
to facilitate resource mobilisation
and implementation
 Implement integrated national
disease
surveillance
system
including VPD and AEFI.
Joint MOH and partners forum will
monitor adherence of PHC service
providers (public/private and
CBO/NGO) to the use of the unified
national HMIS registration and
reporting formats and timeliness of
reporting
Overall Risk Rating for Objective 2 Medium Medium
Objective 3: To support production, equitable distribution and retention of a multi-tasked
facility and community health workforce to meet immunization and PHC needs
Fiduciary Risks:
Medium Medium
Improve the reporting and timely
Delay in fund transfer from GAVI
submission of reports and responses
to FMOH and from FMOH to
to clarifications to GAVI through
state/locality leads to health
regular training of financial and PMU
training institutions not
staff.
producing the required HRH
Strengthen the capacity of the
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HSS Application Materials– 31/05/2013
staff as per plan
finance management units at states
through training and back up.
Implement HRH retention policy.
Provide non-financial incentives and
implement the endorsed FOMH
Performance based incentive
scheme
Institutional Risks:
Medium Medium
Inadequate number and quality
of HRH due to high staff turnover
resulting in suboptimal
performance of programmes.
This may result in slow progress
to achieve programmes’ targets
and inability to sustain the results
Operational Risks:
Low
Medium
Health Workers and Village midwives
High dependency on
will be produced and deployed to
volunteers for implementation
replace volunteers in areas with poor
of outreach and mobile
access to PHC services.
activities affecting
Strengthen partnership with
achievements of targets and
CSOs/NGOs and engage them in the
service sustainability
implementation of the activities.
Overall Risk Rating for Objective Medium Medium
3
Objective 4: To strengthen management and leadership capacity of the decentralized health
system at state and locality levels for an effective and efficient implementation of an
integrated PHC package including EPI services
Fiduciary Risks:
Low
Low
1a. DGIH will provide training to its
Fiduciary Risks:
implementing
partners
and
continuously follow-up by frequent
1. Possibility that funds are not
on-site visits to ensure that the
properly recorded,
processes
of
agreed
upon
accounted for, or reported
procedures are followed.
Low
Medium
2. Possibility that funded
1b. Non-financial incentives should
assets (non-cash) are lost
be provided to encourage and
due to theft
facilitate the fulfilment of proper
reporting.
Such
could
include
provision of mobile phones, laptops,
printers etc.
2a. DGIH and other national
implementers will avoid the use of
vehicles in certain high risk areas
(insecure areas) and rather explore
options such as motorbikes or the use
of public transport.
Institutional Risks:
Inadequate capacity at states
level (lack of appropriate
structures, unfilled vacancies, staff
turnover)
Operational Risks:
Inadequate coordination
capacity negatively impacting
project monitoring at states and
locality levels.
Low
low
Medium
Low

Support the implementation of
decentralized system
Joint monitoring and experience
sharing forums will be
implemented


Recruit zonal project coordinators
Conduct regular supervisory visits

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HSS Application Materials– 31/05/2013
Overall Risk Rating for Objective 4
Low
Medium
TWO PAGES MAXIMUM
18. Financial Management and Procurement Arrangements
In this section applicants are requested to describe:
→ a) The proposed financial management mechanism for this proposal
→b) Financial Management Arrangements Data Sheet: The proposed processes
and systems for ensuring effective financial management of this proposal,
including the organisation and capacity of the finance department and the
proposed arrangements for oversight, planning and budgeting, budget execution
(incl. treasury management and funds flow), procurement, accounting and
financial reporting ( incl. fixed asset management), internal control and internal
audit, and external audit. CSOs can receive GAVI funding through two channels:
(i) funding from GAVI to MOH and then transferred to CSO, or (ii) direct from
GAVI to CSO. Please refer to Annex 4 of the Guidelines for further details
→ c) The main constraints in the (health sector’s) financial management system.
Does the country plan to address these constraints/ issues? If so, please
describe the Technical Assistance (TA) needs in order to fulfil the above
functions.
4 pages (more pages necessary if more than one lead implementer)
Question (a):
applicants
should indicate whether an
existing financial management
mechanism or modality will be
employed (pooled funding,
joint financing arrangements
or other), or if a new approach
is proposed. If an agencyspecific financial arrangement
will be used, specify which
one. A rationale for this choice
should be provided.
The overall management of GAVI HSS funds will be the
responsibility of the Sudan Federal Ministry of Health
(FMOH), which will be carried out in accordance with
government guidelines and procedures, laid down by
the Ministry of Finance and National Economy. This has
been the case for the current GAVI HSS grant.
Continuation in using the exiting financial management
arrangements were recommended by GAVI following
the FMA conducted in March-August, 2012 (Annex 27).
Question (b): Financial Management Arrangements Data Sheet
Any recipient organization/country proposed to receive direct funding from
GAVI must complete this Data Sheet (for example, MOH and/or CSO
receiving direct funding).
1.
Name and contact
information of Focal Point
at the Finance
Department of the
Ayes Amir Ayes,
Financial Manager, GAVI/GFATM HSS Management Unit,
Directorate General of Planning and International Health,
FMOH, Sudan
Mobile: +249123005336
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HSS Application Materials– 31/05/2013
recipient organization
2.
Does the recipient
organization have
experience with GAVI,
World Bank, WHO,
UNICEF, GFATM or other
Development Partners
(e.g. receipt of previous
grants)?
3.
If YES
 Please state the name
of the grant, years and
grant amount.
 For completed or
closed Grants of
GAVI and other
Development
Partners: Please
provide a brief
description of the main
conclusions with
regard to use of funds
in terms of financial
management
performance.
 For on-going Grants
of GAVI and other
Development
Partners: Please
provide a brief
description of any
financial management
(FM) and procurement
implementation issues
(e.g. ineligible
expenditures, misprocurement, misuses
of funds, overdue /
delayed audit reports,
and qualified audit
opinion).
YES. FMOH through Directorate General of Planning and
International Health DGIH is receiving and managing joint
plans with partners (GFATM, GAVI, WHO, UNICEF, UNFPA,
MDTF)
The GAVI Alliance has been supporting the Republic of
Sudan through cash-based support, since 2002 for the
Immunization Services Support (ISS) and since 2008, for
the Health Systems Strengthening (HSS). To date, a total
amount of $ 10,598,300 and $ 16,153,500 has been
disbursed to the Republic of Sudan in the form of ISS and
HSS respectively.
Completed /closed GAVI Grants include: ISS has been
successfully implemented and closed with a total
disbursement of 94% of the approved budget.
Completed /closed Grants from other Development
Partners include: The Multi Donor Trust Fund Decentralized
Health Systems Development Project successfully
implemented and closed in June 2013.
On-going GAVI Grant: The HSS grant, 2008-13 is
successfully implemented with a total disbursement of
100% of the approved budget. Most of the activities were
implemented. The remaining activities will be finalized by
March 2014.
On-going Grants for other development partners
include: Global Fund ATM grant
The GAVI FMA conducted in 2012, deemed the fiduciary
arrangements put in place by the FMoH/Government of
Sudan for the management of GAVI cash support
programmes to be reasonably adequate.
This assessment served as a reference for GF when
conducting a financial assessment of the Directorate
General of International Health in 2012, to assess whether
the directorate had the capacity to take over the role of
Direct Sub-recipient (SR) from WHO in managing the
current GF ATM/HSS grant.
Oversight, Planning and Budgeting
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HSS Application Materials– 31/05/2013
4.
Which body will be
responsible for the incountry oversight of the
programme? Please
briefly describe
membership, meeting
frequency as well as
decision making process.
5.
Who will be responsible
for the annual planning
and budgeting in relation
to GAVI HSS?
6.
What is the planning &
budgeting process and
who has the responsibility
to approve GAVI HSS
annual work plan and
budget?
Oversight of the GAVI HSS grant will be the responsibility
of
the
National
Health
Sector
Coordination
Committee/CCM Sub-Committee (NHSCC/ CCM SubCommittee).
This Committee is
chaired by
Undersecretary
of
the
FMOH
and
includes
representatives from the Federal Ministry of Health,
Ministry of Finance, Ministry of Interior, Ministry of
Defence, development partners such as UNDP, UNICEF,
WHO, Rotary and Non-Governmental Organisations
(NGOs) working in health (Sudanese Red Crescent , Plan
Sudan,). The committee was previously formed within
the national health system to co-ordinate HSS
programme activities funded by both GAVI and GF, with
the intension of harmonizing HSS funding. Recently, the
Inter-Agency Coordinating Committee (ICC) that
oversees the GAVI ISS programme and co-ordinates the
work of agencies and donors who are supporting
immunization and vaccination programmes, has been
integrated within the existing NHSCC/CCM SubCommittee. This new structure aims to insure that GAVI
HSS initiatives are directed towards strengthening EPI
programme and thus improving the coverage and
accessibility of immunization services in Sudan.
The NHSSC meets twice a year and in addition, when the
need arises, as in the case of reprogramming or any other
major issues affecting grant implementation that need to
be decided upon, which get to be raised by the HSS PMU
or committee members. The NHSSC annually reviews
progress in implementation as well as endorses the
Annual Progress Reports before submission to GAVI and
plans for the coming year.
Based on the Aide memoire signed between GAVI and
FMOH, Annual Planning and budgeting is the
responsibility of the relevant FMoH directorates
implementing activities. The plans have to be reviewed
and endorsed by NHSCC/CCM Sub-Committee.
At the beginning of each year the available budget for
each component is identified by the Project
Management,
shared
with
implementing
departments/programmes to prepare their detailed
annual plans based on the approved grant plan and
budget. These plans are derived from the NHSSP,2012-16,
biennium plans and states plans and are shared at
Annual Planning Meetings with states, implementers and
technical partners. These are then presented to the
National Health Sector Coordination Committee for
review and approval.
In the case of EPI, the planning and budgeting process
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HSS Application Materials– 31/05/2013
combines a top down and bottom up approach
whereby annual plans are derived from the 5 year multiyear plan and at the same time incorporating State &
Locality micro-plans. Submitted micro-plans are revised
and finalized/approved at the annual (in February) EPI
meeting with all States and involvement of UNICEF and
WHO. These plans together with HSS plans have to be
reviewed and endorsed by NHSCC/CCM SubCommittee.
7.
Will the GAVI HSS
programme be reflected in
the budget of the Ministry
of Health submitted every
year to the Parliament for
approval?
YES. The budget is reported to Ministry of Finance and the
Parliament for approval and subject to routine internal
and external audit according to the national guidelines
Budget Execution (incl. treasury management and funds flow)
What is the suggested
banking arrangement?
(i.e. account currency,
funds flow to programme)
Please list the titles of
authorised signatories for
payment release and
funds replenishment
request.
Will GAVI HSS funds be
transferred to a bank
account opened at the
Central Bank or at a
commercial bank in the
name of the Ministry of
Health or the
Implementing Entity?
Following the 2012, FMA recommendations, a bank
account denominated in Euro was opened at Blue Nile El
Meshreg Bank which is maintained by the International
Health Directorate to receive GAVI payments as well as
to pay for programme expenditures eligible for GAVI
programme financing. Joint signatories to this bank
account are the Global Health Initiatives Coordinator
(GAVI/GFATM PMU Manager) and the HSS Finance
Manager.
10.
Would this bank account
hold only GAVI funds or
also funds from other
sources (government
and/or donors- “pooled
account”)?
These bank accounts will hold only GAVI funds and they
have been opened especially for that purpose in order to
facilitate Audits of the account. Other grants (GFHSS)
have their own bank accounts for basically the same
reason in the same bank.
11.
Within the HSS
programme, are funds
planned to be transferred
from central to
decentralized levels
(provinces, districts etc.)?
YES
8.
9.
GAVI HSS funds will be transferred to the following bank
accounts:
1) Special Account in name of FMoH in a commercial
bank (Blue Nile El Meshreg Bank) to receive
disbursements from GAVI (in EURO) and then to Local
currency HSS account in order to be disbursed to the
eligible recipients/contractors against approved activities
in the Annual Work Plan.
2) Local currency EPI account (to receive funds from
GAVI Special Account)
Disbursements of GAVI funds to sub-national levels will be
made to the bank account of the respective State
Ministry of Health. States will maintain a separate records
and are subject to routine internal and external audit
according to the national guidelines
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HSS Application Materials– 31/05/2013
If YES, please describe
how fund transfers will be
executed and controlled.
Procurement
12.
What procurement
system will be used for
the GAVI HSS
Programme? (e.g.
National Procurement
Code/Act or
WB/UNICEF/WHO and
other Development
Partners’ procurement
procedures)
All goods, works and services required for the HSS grant
that will be purchased with the proceeds of GAVI funds
will be procured in accordance with the Government of
Sudan procurement law, rules and guidelines, currently
contained in the Procurement Act (2010), the
Procurement Regulation (2011) and any decrees that
may be issued in the future by the Ministry of Finance and
National Economy (“MoFNE”).
13.
Are all or certain items
planned to be procured
through the systems of
GAVI’s in-country
partners (UNICEF,
WHO)?
Cold chain equipments will be procured by UNICEF due
to its comparative advantages and based on previous
experience.
14.
What is the staffing
arrangement of the
organization in
procurement?
Procurement for all GAVI programmes will be managed
by the FMoH by the procurement officers within the
Project Management Unit (PIU) for HSS, and the
respective Procurement Committee, for EPI according to
the government regulations.
1.
An Annual Procurement Plan (APP) will be prepared on
the basis of the Annual Work Plans Budgets (AWPB). The
APP for each Government of Sudan financial year will be
submitted to the NHSSC/Sub CCM for review and
approval, prior to the start of the relevant Government of
Sudan financial year and implementation. A copy of the
approved APP will be provided to GAVI together with the
AWPB prior to implementation of the procurement
activities.
15.
Are there procedures in
place for physical
inspection and quality
control of goods, works,
or services delivered?
YES. National Regularity Authorities are in place to ensure
the safety and quality of goods. National Poisons and
Medicine Board and Sudan Standard and Metrology
Organization will check the specifications and apply the
quality procedures for the medical equipments, goods
and works.
16.
Is there a functioning
complaint mechanism?
Please provide a brief
description.
YES. The first level is the bidding committee then the
Undersecretary of FMOH then Ministry of Finance then the
Court.
(If YES, please describe)
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HSS Application Materials– 31/05/2013
17.
Are efficient contractual
dispute resolution
procedures in place?
Please provide a brief
description.
YES. National Procurement Act 2010 has described the
contractual dispute resolution procedures. Further more
in each contract the mechanism and the procedures of
dispute resolution will be discussed and agreed with the
contractors before signing the contracts.
(If YES, please describe)
Accounting and financial reporting (incl. fixed asset management)
18.
What is the staffing
arrangement of the
organization in
accounting, and
reporting?
Accounting is the responsibility of the financial staff
provided by the Chamber of Accounts. Accounting and
reporting of the GAVI programmes is performed within
the Primary Health Care (PHC) Finance Unit for the EPI
programme and the Internal Health Finance Unit for the
HSS programme.
19.
What accounting system
is used or will be used for
the GAVI HSS
Programme? (i.e. Is it a
specific accounting
software or a manual
accounting system?)
Sudan follows a cash-based system of accounting which
is primarily manual with the Financial Regulations of 1995
(updated in 2011) prescribing the various ledgers that
need to be maintained. The PMU and EPI programme
have implemented accounting software to facilitate their
accounting.
20.
How often does the
implementing entity
produce interim financial
reports and to whom are
those submitted?
The HSS Grants Implementation Team with the responsible
Finance Officer, prepares and provides to the
Undersecretary FMOH and NHSCC/ CCM Sub-committee,
with a copy to GAVI, within 45 days after the end of each
quarter, Interim unaudited Financial Reports (“IFRs”) of
the GAVI HSS programme covering the relevant quarter.
Internal control and internal audit
21.
Does the recipient
organization have a
Financial Management or
Operating Manual that
describes the internal
control system and
Financial Management
operational procedures?
YES
22.
Does an internal audit
department exist within
recipient organization? If
yes, please describe how
the internal audit will be
involved in relation to
YES
FMoH has its own, dedicated IA unit which is staffed by 11
auditors, 1 Deputy Manager and headed by the
Manager. Of the auditors, 8 have been posted to various
departments, including EPI and International Health
handling GAVI HSS funds.
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HSS Application Materials– 31/05/2013
GAVI HSS.
23.
Is there a functioning
Audit Committee to follow
up on the implementation
of internal audit
recommendations?
GAVI cash grants are included in the scope and Annual
Work Plans of the Internal Audit Unit FMoH. The Internal
Audit Unit of the FMoH has issued clear guidance,
describing the tasks to be performed by the Internal
Auditors carrying out verifications in relation to the
financial management of GAVI cash grants, to be
applied to HSS funds.
The follow up of the implementation of internal audit
recommendations is done by the internal auditor posted
to DGIH and PHC departments and the manager of the
IA Unit.
External audit
24.
Are the annual financial
statements planned to be
audited by a private
external audit firm or a
Government audit
institution (e.g. Auditor
General)?3
The external audit for GAVI cash grants is performed by
the National Audit Chamber (NAC) of Sudan. It covers
aspects of programme activities implemented and
includes
verification
of
expenditures’
eligibility,
procurement, programmes performance and physical
inspection of goods, works and services acquired.
Audited financial statements for GAVI grant for each
period are then provided to the NHSCC/ CCM SubCommittee within a period of six months.
25.
Who is responsible for
the implementation of
audit recommendations?
Implementation of audit recommendations is the
responsibility of HSS PMU, EPI, Implementing departments,
States and other implementers depending on the
recommendation.
THREE PAGES MAXIMUM
Question (c): Please indicate the main constraints in the (health sector’s)
financial management system. Does the country plan to address these
constraints/ issues? If so, please describe the Technical Assistance (TA) needs in
order to fulfil the above functions
The main constraint in the health financial management system has been dealing with multiple
donors with different reporting and financial requirements mainly resulting from the inadequate
number of staff in the finance departments particularly, at state level.
FMOH is implementing a long term plan to strengthen the capacity of the financial system at
federal and state levels. This plan was developed following the Financial Management
Assessment FMA conducted by GAVI in 2012 and the financial assessments conducted by
GFATM/UNDP 2012/2013. The recommendations of these assessments are being addressed.
FMOH has developed a financial manual with the objective of unifying different financial
procedures and aligning them with the national financial guidelines and regulations. Technical
assistance has been provided by GFATM/UNDP to support FMOH in improving the financial
3
If the annual external audit is planned to be performed by a private external auditor, please include an appropriate audit fee within the
detailed budget.
77
HSS Application Materials– 31/05/2013
system. A training workshop, facilitated by an international consultant was organized in
December 2013 for the financial and programme staff from federal and states MOH. A handson training is planned for the states’ financial staff during the supportive supervisory visits from
federal level. A national unified asset management system, which includes regular asset
verification, is currently under establishment to manage assets provided by different partners
and donors.
HALF PAGE MAXIMUM
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HSS Application Materials– 31/05/2013
SUMMARY OF A COMPLETE APPLICATION
HSS Proposal Forms and Mandatory GAVI attachments
→ Please place an ‘X’ in the box when the attachment is included
No. Attachment
1.
2.
HSS Proposal Form
Signature Sheet for Ministry of Health, Ministry of Finance and Health Sector
Coordinating Committee (HSCC) members
HSS Monitoring & Evaluation Framework
Detailed work plan and detailed budget
3.
4.
X
X
X
X
Existing National Documents - Mandatory Attachments
Where possible, please attach approved national documents rather
than drafts. For a highly decentralised country, provide relevant
state/provincial level plan as well as any relevant national level
documents.
→ Please place an ‘X’ in the box when the attachment is included
No. Attachment
5.
National health strategy, plan or national health policy, or other documents
attached to the proposal, which highlight strategic HSS interventions (Annex
5)
National M&E Plan (for the health sector/strategy) (Annex 15)
National Immunisation Plan (Annex 31)
Country cMYP (Annex 12)
Vaccine assessments (EVM, PIE, EPI reviews), if available (Annex 20-1& 20-2)
Terms of Reference of Health Sector Coordinating Committee (HSCC)
(Annex 22)
6.
7.
8.
9.
10.
X
X
X
X
X
X
Existing National Documents - Additional Attachments
Where possible, please attach approved national documents rather
than drafts. For a highly decentralised country, provide relevant
state/provincial level plan as well as any relevant national level
documents.
→ Please place an ‘X’ in the box when the attachment is included
No. Attachment
1.
Joint Assessment of National Health Strategy (if available) (Annex 13)
2.
Response to Joint Assessment of National Health Strategy (if available)
(Annex 14)
X
X
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HSS Application Materials– 31/05/2013
3.
4.
If funds transfers are to go directly to a CSO or CSO Network, please provide
the 3 most recent years of published financial statements of the lead CSO,
audited by a qualified independent external auditor
EPI routine coverage by states 2012 (Annex 6)
X
5.
Sudan National Health Policy ,2007 (Annex 7)
X
6.
The Interim National Constitution of the Republic of Sudan, 2005 (Annex 8)
X
7.
IHP+ Results monitoring process report 2012 (Annex 9)
X
8.
Equitable distribution of health resources (Annex 10)
X
9.
National Health Accounts, 2010 (Annex 11)
X
10. Health System’s Performance Assessment Report (Annex 16)
X
11. Joint Annual Review TORs ( Annex 17)
X
12. Health Systems Bottleneck Analysis for EPI (Annex 18)
X
13. GAVI/GFATM Health Systems Bottlenecks Consultation Workshop Report, 21
November, 2013 ( Annex 19)
14. Promoting access to high quality PHC services in Sudan 2012 (Policy Brief)
(Annex 21)
15. Undersecretary Decrees for Formulation of Technical Committees for the
Development of new applications for GAVI and GF (Annex 23)
16. NHSCC/CCM HSS SUB-Committee and committees meeting minutes (Annex
24-1 to 24-16)
17. Plan of Action POA for Application Development (Annex 25)
X
18. Health and Nutrition Recovery Strategy for Darfur ,2012 – 2016 (Annex 26)
X
19. GAVI Financial Management Assessment,2012 (Annex 27)
X
20. Salary Top-ups scheme (Annex 28)
X
21. HSS Project Management Unit Organizational Structure (Annex 29)
X
22. Investment Plan Survey, 2010 (Annex 30)
X
23. Year one detailed budget and assumptions (additional) (Annex 32)
X
24. PHC, EPI coverage among underserved and disadvantaged communities
and the key interventions by state (Annex 33)
25. Detailed Technical assistance Plan (Annex 34)
X
X
X
X
X
26. National response to WHO HQ pre-review recommendations (Annex 35)
27. List of abbreviations (Annex 36)
X
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HSS Application Materials– 31/05/2013
Applicants are strongly encouraged to carefully read the
instructions provided within the relevant sections of the
guidelines before completing the application form.
81
HSS Application Materials– 31/05/2013