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Cablegate: Sudan - Health Sector Relief to Development Transition

VZCZCXRO2191
PP RUEHGI RUEHMA RUEHROV
DE RUEHKH #0679/01 1211043
ZNR UUUUU ZZH
P 011043Z MAY 07
FM AMEMBASSY KHARTOUM
TO RUEHC/SECSTATE WASHDC PRIORITY 7042
INFO RUCNFUR/DARFUR COLLECTIVE PRIORITY
RUEHRN/USMISSION UN ROME

UNCLAS SECTION 01 OF 02 KHARTOUM 000679

SIPDIS

AIDAC
SIPDIS

STATE FOR AF/SPG, PRM, AND ALSO PASS USAID/W
USAID FOR DCHA SUDAN TEAM, AFR/SP
NAIROBI FOR USAID/DCHA/OFDA, USAID/REDSO, AND FAS
GENEVA FOR NKYLOH
NAIROBI FOR SFO
NSC FOR PMARCHAM, MMAGAN, AND TSHORTLEY
ADDIS ABABA FOR USAU
USUN FOR TMALY
BRUSSELS FOR PLERNER

E.O. 12958: N/A
TAGS: EAID PREF PGOV PHUM SOCI UN SU
SUBJECT: SUDAN - HEALTH SECTOR RELIEF TO DEVELOPMENT TRANSITION
UPDATE


KHARTOUM 00000679 001.2 OF 002


-------
SUMMARY
-------

1. (U) Nearly two decades of civil war in Southern Sudan has
resulted in a region with some of the worst health indicators in
sub-Saharan Africa. As USAID prepares to transition its assistance
in the region from relief assistance to development programming,
USAID's health sector non-governmental organization (NGO) partners
are encountering significant challenges. To assist with this
difficult transition, USAID is developing a comprehensive transition
plan for assistance to Sudan in the health sector. As part of this
effort, the Health, Disaster, and Complex Emergencies Advisor of the
USAID's Bureau of Global Health's Office of Health, Infectious
Diseases, and Nutrition traveled to Sudan and Nairobi, Kenya, from
February 25 to March 15. The USAID staff found that the potential
for development of strong partnerships with local health officials
is currently limited. In addition, implementation of centrally
controlled development funding such as the Multi-Donor Trust Funds
(MDTF) are behind schedule. Despite high morbidity and mortality
rates in the region, opportunities exist to transition from relief
to development assistance. End Summary.

----------
BACKGROUND
----------

2. (U) After decades of war in Sudan, many regions of the country
have some of the worst health indicators in sub-Saharan Africa.
Massive destruction of health infrastructure and erosion of human
resources have resulted in a maternal mortality ratio (MMR)
estimated at 1,700 maternal deaths per 100,000 live births and an
under-five mortality ratio (U5MR) close to 250 deaths per 1,000 live
births, according to the findings of the Joint Assessment Mission in
2005. In 2000, the sub-Saharan Africa MMR average was 920 per
100,000 live births. In 2003, the U5MR was 175 per 1,000 live
births. Despite these dismal health statistics, significant
progress has been made since the signing of the Comprehensive Peace
Agreement (CPA) in both development and humanitarian assistance
arenas to address the needs of the people in Southern Sudan.

3. (U) From February 25 to March 15, USAID staff met with
implementing partners, other donors, the Government of National
Unity (GNU) Federal Ministry of Health (FMOH), and the Government of
Southern Sudan (GOSS) Ministry of Health (MOH). This assessment was
the first in a series that will inform the development of a
comprehensive transition plan for USAID's assistance in the health
sector. The purpose of the assessment was to gather information on
the status of the health sector in Sudan. In addition, USAID staff
reviewed USAID development and humanitarian funding for the health
sector, other donors' plans and initiatives, GOSS and GNU health
policies and funding plans, and the country plans of NGOs.

-------------------------
OVERVIEW AND KEY FINDINGS
-------------------------

4. (U) In meetings with stakeholders, USAID staff focused
discussions on current health activities, sources of funding, and
challenges and opportunities in transitioning health services.
Stakeholders expressed several common themes that are summarized
below.

--LIMITED CAPACITY OF STATE AND LOCAL MINISTRIES OF HEALTH: NGO
partners noted the lack of trained health care workers as a
significant challenge in Sudan. In some areas, especially those
formerly controlled by the Government of Sudan (GOS) during the war,
the state MOH has been able to provide health care workers and
salaries to support NGO-led health programs. However, in areas
formerly controlled by the Sudan People's Liberation Movement (SPLM)
there is limited MOH capacity to second health staff or pay
salaries, causing NGOs to pay "incentives" and recruit staff from
outside the area. Consequently, prospects for transitioning
programs to the MOH in former SPLM-controlled areas are limited. As
the GOSS is still in the process of organizing state and county
administrations, forging effective partnerships with the GOSS is
difficult. The health sector in Southern Sudan faces a human
resource gap due to the migration of workers out of the health
sector to more lucrative positions. All NGO partners include
capacity building for state and local MOH staff counterparts, but

KHARTOUM 00000679 002.2 OF 002


additional needs exist.

--LIMITED MEDICINE SUPPLY MECHANISMS: Partners report a fragmented
medicine supply system with most partners accessing pharmaceuticals
through the UN Children's Fund (UNICEF). Some organizations that
receive medicine through UNICEF have experienced delays in delivery
and have noted significant medicine wastage since the medicine
package is standardized and does not always reflect local needs.
UNICEF is currently the principle provider of medicine to health
partners in the Three Areas. However, at the end of 2007, UNICEF
reportedly plans to cease this service. In 2007, the FMOH will need
to assume this responsibility using Multi-Donor Trust Fund
resources.

--UNCERTAINTY SURROUNDING THE MULTI-DONOR TRUST FUNDS: Per the CPA,
the GNU has established Multi-Donor Trust Funds for Southern Sudan
and the conflict-affected states in northern Sudan. The funds are
managed by the World Bank in cooperation with GNU ministries and
implemented in multiple phases. MOH officials plan to use
Multi-Donor Trust Fund resources to contract NGOs for health
services delivery. In the north, the FMOH believes it can manage
the health sector transition from being donor-supported to public
sector-supported, especially in the former garrison towns. However,
GOSS MOH officials openly acknowledge that they have limited
experience in managing such an undertaking. Additionally, the
process for distributing funds under the Multi-Donor Trust Fund
process has been slow and confusing. A significant limitation of
the Multi-Donor Trust Fund for Southern Sudan is the GOSS MOH's
assumption that the funds are meant to augment current humanitarian
and bilateral funding in the health sector, and not replace donor
investments.

--LIMITED DEVELOPMENT FUNDING OPTIONS: Sudan's health sector has
limited development funds currently available. USAID partners
report a "quiet crisis" in the remote areas of non-Darfur Sudan,
where morbidity and mortality rates remain at emergency levels.
These communities may begin to experience a "peace penalty" in
health services as emergency-focused agencies begin to close-out
operations. The reduced services coupled with inadequate MOH
presence and capacity to manage health activities at the county
level are likely to have a negative impact on already vulnerable
communities. Aside from the GNU or Multi-Donor Trust Funds, other
long-term health sector development programs are limited to: smaller
European Union-funded programs; some bilateral funding from the
Netherlands, Ireland, and Denmark; the UK's Department for
International Development (DFID); the Common Humanitarian Fund
(CHF); and the USAID/Sudan Health Transformation Project (SHTP).
USAID's Office of U.S. Foreign Disaster Assistance (USAID/OFDA) and
USAID/Sudan's health team staff are working together to identify
potential transition opportunities from USAID/OFDA funding to SHTP
development programming.

5. (U) Despite the challenges, opportunities for transition exist,
especially in urban and peri-urban areas and in states where the
Multi-Donor Trust Funds are likely to commence in 2007.

----------
NEXT STEPS
----------

6. (U) The next steps for health sector transition planning include
further assessment of current USAID partner activities and the
development of specific recommendations on future USAID investments,
both humanitarian and developmental.

7. (U) Convening a transition planning workshop for the health
sector would be extremely timely and beneficial in the coming
quarter. The purpose of the workshop would be to bring together all
the relevant partners in the GOSS MOH to identify gaps,
opportunities, and needs in health as the sector transitions from
relief to development in 2007 and 2008. It is envisioned that the
meeting would be chaired by the MOH and would bring together the
donors, NGOs, and state-level MOH staff to discuss the current
status of the health sector and plan the way forward.

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