2012-2016fmoh.gov.sd/St_Paln/StEpiJune Version.pdf · Dr.Babikir Ahmed Magboul Somia Okoud Dr.Magdy Mahjoub Dr. Mohammed Abdelrahman Dr. Linda Awad Mustafa Dr.Layla Abdullah Dr. Ali

FEDERAL MINISTRY OF HEALTH

EPIDEMIOLOGY & ZOONOTIC

DISEASES DEPARTMENT STRATEGIC

PLAN

2012-2016

JUNE 2011

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EPIDEMIOLOGY & ZOONOTIC DISEASES DEPARTMENT STRATEGIC PLAN – JUNE 2011

Contents

1.1 Foreword ........................................................................................................................................... 5

1.2 Acknowledgements and contributors ............................................................................................... 6

1.3 Abbreviations .................................................................................................................................... 7

1.4 Executive Summary ........................................................................................................................... 8

2.1 Background: .................................................................................................................................... 10

2.2 Scope: 10

2.3 Identity of the department: Who we are ....................................................................................... 11

2.3.1 Vision ........................................................................................................................................ 11

2.3.2 Mission statement ................................................................................................................... 11

2.3.3 Values: ...................................................................................................................................... 12

2.4 Methods of developing StEpi .......................................................................................................... 12

3.1 An overview of disease epidemiology and PHEIC in Sudan ............................................................ 14

3.2 Policy context .................................................................................................................................. 16

3.3 Structure, Function and Resources (FMoH Dept) ........................................................................... 17

3.3.1 Department Structure as of 2010: ........................................................................................... 17

3.3.2 Function of each unit ............................................................................................................... 17

3.3.3 Gaps - Functions not currently covered (as of 2010): .............................................................. 18

3.3.4 Staffing in the department....................................................................................................... 19

3.3.5 Analysis of budgets .................................................................................................................. 20

3.4 Strategic relationships .................................................................................................................... 21

3.4.1 Cross-Cutting Activities with other FMoH departments .......................................................... 21

3.4.2 Epidemiology departments in States ....................................................................................... 22

3.4.3 Epidemiology departments in localities ................................................................................... 23

3.4.5 External stakeholders and partnerships .................................................................................. 24

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3.5 Summary of situation analysis (SWOT) ........................................................................................... 25

4.1 Strategic issues ................................................................................................................................ 26

4.2 Strategic Objectives and Strategies ................................................................................................ 27

4.3 Overview of Strategic Plan of the Epidemiology Department, FMOH ............................................ 28

(StEpi) 2012- 2016 ............................................................................................................................. 28

5.1 Strengthen States to undertake their decentralised functions ...................................................... 29

5.2 Develop Staff competence at Federal level ................................................................................ 3130

5.3 Develop the network for mutual support across levels .............................................................. 3231

5.4 Develop Evidence to support decision making: .......................................................................... 3332

5.5 Develop Strategic partnerships to enable the transformation: .................................................. 3433

6.1 Establish an Integrated Surveillance system ............................................................................... 3534

6.2 Emphasise systems of early preparedness and manage logistics ............................................... 3635

6.3 Respond to all PHIEC ................................................................................................................... 3736

6.4 Undertake rapid response to Outbreak/Incident Control .......................................................... 3837

6.5 Strengthen liaison functions (Zoonotic Disease, Ports & Quarantine) ....................................... 3938

7.1 Modifying organisational structure ............................................................................................ 4039

7.2 Attracting Resources needed to fill the gap ............................................................................... 4140

7.3 Change management models: .................................................................................................... 4140

7.4 Enabling legislation ..................................................................................................................... 4140

7.5 Action Planning and M&E requirements .................................................................................... 4140

Appendix 1: Epidemiology dept plan for 2011 ................................................................................. 4746

Appendix 2: Principles of surveillance and response (Report of stakeholder workshop with MoH

departments, 7 March 2011): ........................................................................................................... 5554


departments, 7 March 2011): ........................................................................................................... 5554

Appendix 3: Stakeholder perspectives outside MoH (Report of workshop, 17 March 2011): ......... 5756

Appendix 4: Staff development model suggested by CDC, April 2011 ............................................. 5857

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1. Preamble

1.1 Foreword In our rapidly developing world that heads more everyday towards the global village, health threats

strike fast and spread even faster. New challenges in health are emerging with brand new offenders

and within hours they would invade across the globe. H1N1, Avian flu and SARS are all examples of

how old rules are no longer valid and that new mentality and approach are needed to face these and

any other potential public health risks. Here in Sudan, the need for a well-structured, scientifically

developed strategic plan is undoubtful, not only to guide our effort in protecting the Sudanese

nation from vicious outbreaks but also to build our capacity in a systematic and innovative way to

better carry out our share in keeping the international health.

The Department of Epidemiology and Zoonotic Diseases is one of the oldest departments in the

Federal Ministry of Health. Throughout its history it has proved to be the guardian of the public from

all kind of epidemics and public health emergencies, which, understandably, are tremendous in a

country with geographical location and size like Sudan. The department has always been up to the

challenge and over the years has developed and reformed itself seeking for a better performance

and accommodating the local demands and the international requirements.

The strategic plan 2012-2016 for the Department of Epidemiology and Zoonotic Diseases is a

product of high quality scientific efforts using the up-to-date international standards of planning

while deeply understand the particularity of Sudan. I believe this plan has been developed after

thorough study of the situation at the state level and with the involvement of key persons and

relevant stakeholders, and therefore we should expect smooth and fruitful application and

implementation of its components.

On behalf of the Federal Ministry of Health, I would like to acknowledge the efforts invested by the

strategic plan development team. My sincere thanks extended to all who participated in various

steps of the plan development from inside the Ministry and from stakeholders. Special gratitude

goes to the Public Health Institute for facilitating the process; it is definitely a distinguished kick off

of its consultancy activities.

All in all this work is a milestone towards achieving the vision of the Federal Ministry of Health and in

fulfilling its mission in the second decade of the millennium. I’ll be looking forward for translating

the words of the plan into actions

Dr. Isameldin M. Abdalla

Undersecretary

Federal Ministry of Health

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1.2 Acknowledgements and contributors Federal MoH Staff: Dr.Babikir Ahmed Magboul Somia Okoud Dr.Magdy Mahjoub Dr. Mohammed Abdelrahman Dr. Linda Awad Mustafa Dr.Layla Abdullah Dr. Ali ElKarrar Eltayeb

Dr.Hanadi ElAwad Hussien Nawal Ali Sala Nabeeha Abdulla Asma Ahmed Idrees Fatima Osama Salim Islam Eisa Leena Osman Salma Ali Elnowairy

State MoH departments: Tai Allah Ali Tai Allah Hayat Salah EldinKhogali Badawi Hassan Badawi Ahmed AbdallaAbdalla YounisHaroun Adam Amira Hassan A/Rahman DawelbeitElZainAbdalla Ali Merghani Mohamed TahaniElAmin Yousif Mohamed Yousif Ali A/Rahman Mohamed Khadiga Ahmed

Adil Abdel Majeed ElGaily Ramadan GehanKhogali ZainElAbdeenElSafi Eiman Mahmoud Hala Ismail Hussain Faisal Abbas Omer Sulaiman Mohamed Nafie Hamouda Ali Hamouda AbuMedian A/Rahman YousifAbdelBagi ElHussain Mohamed Ibrahim Adil Ahmed Ismail

Steering Committee: Dr Isam Mohamed, Under Secretary Dr ElTayeb ElSayed, D.G., Public Health and Emergencies Dr Talal ElFadil, D.G., PHC Dr Sadig Mahgoub (AFP surveillance)

Dr Mubarak ElKarsani, PH Labs Dr Hayat Khogali, Khartoum State MoH Dr HananMukhtar, Health Promotion dept Dr Louran Ali, Policy section

Policy facilitators: Dr Louran Ali (Head of Policy section, FMoH)

Reel Mutasim (FMoH Policy section) Islam Eisa

Strategy facilitators Dr Muna I Abdel Aziz (PHI) Dr Dalia YM ElKhair (Univ of Khartoum)

Dr SayedHimat (EpidDept) Dr Ahmed ElTahir (EpidDept) Dr AmjadWedaa (PHI project manager)

Field visits Gezira, Red Sea, White Nile States

State and locality Epidemiology depts, sample sentinel sites and localities, NGOs and community leaders

Comments received from a number of individuals formerly at Epidemiology Dept or partner organsitions

Comments received from CDC mission to Sudan: Dr Henry Walke, Dr Stephen Becknell and Dr Omar Makki

Participants in MoH Departments workshop (appendix 5)

Participants in external partners workshop (appendix 6)

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1.3 Abbreviations

Dept Department

EPR Early preparedness and response

FETP Field Epidemiology Training Programme

FMOH Federal Ministry of Health

IHR International Health Regulations 2005

MoAR Ministry of Animal Resources

MoH Ministry of Health

P&Q Ports & Quarantine dept

PHEIC Public Health Events of International Concern

RASCI Responsible, Accountable, Supportive, Consult, Inform (Management model)

RRT Rapid response team

SOPs Standard Operational Guidelines

StEpi Strategic Plan for the Epidemiology department

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1.4 Executive Summary The Epidemiology Department, Federal Ministry of Health, is one of the departments

within the Directorate of Public Health and Emergency. This dept. plays a critical role

in prevention, management and containment of outbreaks, and furthermore in early

preparedness (planning and proactive development of systems and processes to

reduce the risk and effect of harmful events). It interacts with other partners, within

and outside FMOH, to fulfil its public health role.

The Strategic Plan for the Epidemiology Department 2012 to 2016 (StEpi) comes at

a time of great change in the country with the outcome of the Sudan Referendum

and where new emerging and re-emerging diseases have started to take hold, in

addition to historically challenging communicable diseases. StEpi sets out strategic

objectives to sustain the department‟s efforts to meet the requirements of IHR 2005,

and develop its role of early preparedness and response to PHEIC, in the context of

the 25 year National Health Policy, the upcoming five-year Health Strategy 2012 -16,

the International Health Regulations 2005, and relevant legislations in the country

including the Public Health Act.

A review of the department‟s functions, and a description of how they interrelate, was

conducted during a staff meeting focusing at the internal functioning of the

Epidemiology dept. This was followed by key informant interviews with unit heads of

function.

Furthermore, wide stakeholder involvement was initiated including the establishment

of a parallel policy group to address cross-cutting issues and clarify demarcation of

roles and responsibilities across the different partners. Also, field visits were

undertaken; initially to Gezira State sentinel site, locality and State levels, followed

by a field visit to White Nile State to assess community engagement. A training visit

to Port Sudan was also used for feedback. State perspectives were explored in a

one day workshop held in January with State Directors and Heads of Epidemiology

Departments.

Two extra workshops, with wider stakeholders internal and external to Federal MOH,

were held to affirm the situation analysis, clarify respective roles and responsibilities,

gain ownership, and to agree the strategic shift that is required and the enablers.

The following strategic objectives were concluded:

1. Strategic Objective (Transformational): To transform the network into its vision of

excellence with efficient Epidemiology departments at all levels that can forecast and

control all public health emergencies of concern.

2. Strategic Objective (Transactional): To improve day to day work of early

preparedness, early detection and containment of outbreaks/incidents.

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These were translated into more specific objectives and recommendations, as

follows:

Transformational:

1. Strengthen States to undertake their decentralised functions

2. Develop staff competence at State and Federal levels

3. Develop the network for mutual support across levels

4. Develop evidence to support decision making

5. Develop strategic partnerships to enable the transformation

Transactional:

1. Establish an integrated surveillance system to detect all types of PHEIC

2. Emphasise systems of early preparedness that enable efficient management of

logistics

3. Set up mechanisms to respond to all PHEIC as per IHR implementation

4. Undertake rapid response to outbreaks and incidents

5. Strengthen liaison functions regarding zoonotic diseases and with P&Q for IHR.

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2. Introduction and Methods

2.1 Background: The Epidemiology Department, Federal Ministry of Health plays a critical role in

prevention, management and containment of outbreaks, and furthermore in early

preparedness (planning and proactive development of systems and processes to

reduce the risk and effect of harmful events). As one of the departments within the

Directorate of Public Health and Emergency, the department interacts with other

departments and organisations to fulfil its public health role.

The department have adopted the WHO definition of health: “Health is a state of

complete physical, mental and social well-being and not merely the absence of

disease or infirmity” ((WHO Constitution; 1948). This is because diseases and health

risks often emerge from the wider social and environmental determinants of health

including lifestyles and economic considerations, interaction of man with

environment, displacement in times of conflict, social determinants and infrastructure

of services in times of peace.

During the last decade, there have been changes in disease profile and health

events, international policy change mainly reflected in the International Health

Regulations 2005, and more recently there have been established new national

structures within Federal Ministry of Health. The department is now ready to embark

on a transformational cycle of development to develop its role from reactive to

proactive, from sentinel surveillance to integrated surveillance and predictive

modelling, and from central-led to decentralised operations in partnership with

States.

2.2 Scope:

The Strategic Plan for the Epidemiology Department 2012 to 2016 (StEpi) comes at

a time of great change in the country with the forthcoming separation of South Sudan

and also at a time where new emerging and re-emerging diseases have started to

take hold as well as historically challenging communicable diseases. The Strategic

Plan is timely to enable the department to grow and develop in the context of the 25

year National Health Policy, the upcoming five-year Health Strategy 2012 -16, the

International Health Regulations 2005, and relevant legislations in the country

including the Public Health Act.

StEpi builds upon preceding and concurrent work in the department; including the

FMoH Policy for Epidemiology functions that is currently under development, IHR

2005 Sudan report (conducted in 2010), and the periodic reports of the surveillance

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system, the most recent of which covers 2010. A summary of the main points of

policy is given in section 3.2, and the situation analysis does include an overview of

the current position for diseases currently under surveillance (section 3.1).

StEpi is mainly a communication and planning tool for the department that focuses

on core functions and a roadmap to achieve the vision. Having said that, it is also not

„inward facing‟; as it does prompt the department to be „outward facing‟ in

relationships with key stakeholders and partners in States, localities and

communities, and at the Federal national level and internationally. It is essential to

foster these key relationships whereby partners and stakeholders each play their

part and have clear roles and responsibilities at times of emergencies, outbreaks and

in between. In the spirit of decentralisation, the federal department is well placed as

the hub in a network of Epidemiology departments in States.

While the department has been „fire-fighting‟ to date to keep on top of disease

outbreaks across the country, a hidden epidemic of chronic disease has crept upon

the country, and StEpi proposes to collaborate with others to put in place

epidemiological surveillance as a minimum. Add to that chemical, toxicological and

nuclear threats as well as terrorism on the international scene. The International

Health Regulations have included these as public health emergencies of

international concern (PHEIC) and the department through StEpi affirms its

leadership role in initiating work streams in these respects.

This plan therefore sets out the strategic objectives to sustain the department efforts

to meet the requirements of IHR 2005 and to develop its role in relation to early

preparedness and response to PHEIC. It also sets out the strategic direction to

develop staff and the network in States, attract resources, and proactively enable the

shift that is required in partnership with the key stakeholders.

2.3 Identity of the department: Who we are

2.3.1 Vision

A centre of epidemiological excellence based on a hub and spoke model, and with

systems for early preparedness, integrated surveillance and forecasting, and with

decentralised rapid response to outbreaks and public health events of concern.

2.3.2 Mission statement

We are an effective department in Sudan Federal Ministry of Health responsible for

the federal response to outbreaks and significant events affecting the nation‟s health.

We aim to achieve a high level of public health by early detection, containment and

reporting of health events that are of public health importance both in the Sudanese

and the international community. We do this by early planning, coordinating States

activities, and good collaboration with stakeholders, partners from other sectors and

involving the communities we serve.

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2.3.3 Values:

Technical and scientific excellence: We do this by having an efficient power for

detection and containment, resources for outbreak management, diagnosis and

treatment, technical standards for scientific methods and good documentation

systems.

Professionalism: We do this through well trained, qualified staff working in efficient

units and with a specific focus on capacity building of our staff and partners,

continuous professional development, and Health and Safety.

Evidence based: We do this by having strong information systems, advanced ability

to perform researches and studies, and through developing clear protocols to

support sound decision making.

Partnership: We do this by planning, organising, sharing information, allocating

roles and responsibilities, and coordination with all concerned parties; within the

department and outward facing. We encourage partnership with all stakeholders in

all activities from planning to implementation and evaluation based on mutual

respect and transparency.

Decentralisation: We do this by strengthening the network, coordinating activities,

building capacity and supporting States to undertake their roles.

Community oriented: We do this by health education and involvement of the

community at the locality level. Through early preparedness and response, our work

contributes to a healthy nation with healthy interaction between humans, animals

and the environment.

Open, ethical and equitable: We work to reduce the impact of health events

wherever they occur, regardless of race, gender, place or religion. We do this by

efficient use of available resource, prioritisation of scarce resource, and collaborating

with relevant partners.

2.4 Methods of developing StEpi For the internal functioning of the department, a staff meeting was held in December,

followed by key informant interviews with unit heads of function. Through this, a

review of department functions was undertaken and a description of how they

interrelate. This focused on the surveillance system as well as the other key core

functions.

A review of key documents was initiated (including IHR and department situation

analysis for the surveillance system). A cross-cutting activities grid was completed to

clarify interrelations within the department and outside.

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Internal review (Federal Epidemiology dept)

Topics: Department identity, functions, critical issues and strategic shift needed

To develop a road map for the strategic plan, wide stakeholder involvement was

initiated. This included the establishment of a parallel policy group to address cross-

cutting issues and clarify demarcation of roles and responsibilities across several

departments. Simultaneously, involvement of States was initiated as the State level

strategic plans nest within the Federal department Strategic Plan (StEpi). Field visits

were undertaken; initially to Gezira State sentinel site, locality and State levels,

followed by a field visit to White Nile State to assess community engagement. A

training visit to Port Sudan was also used for feedback. State perspectives were

explored in a one day workshop held in January with State Directors and Heads of

Epidemiology Departments.

Field visits

Case studies of States sentinel sites and locality levels

States Workshop

Topics: Situation analysis in States, Vision, Strategic plans in States

Two workshops were held in March with wider stakeholders internal and external to

Federal MOH. The purpose of these workshops was to affirm the situation analysis,

clarify respective roles and responsibilities, gain ownership, and to agree the

strategic shift that is required and the enablers.

Stakeholder Workshop 1

Topics: Cross-cutting activities within MoH and intentions for transformational work.

Functional components around IHR, outbreak control and incidents, early

preparedness, integrated surveillance. Key policy issues.

Stakeholder Workshop 2

Topics: Strategic relationships with key stakeholders outside MoH. Transformational

strategic shift that is required. Developing evidence. Responding to all PHEIC as per

IHR. Considering liaison/ coordination mechanisms, including Zoonotic Diseases,

New and emerging threats.

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3. Situation Analysis

3.1 An overview of disease epidemiology and PHEIC in Sudan A recent situation analysis was undertaken for the IHR 2005 Sudan report 1 which

sums up that the country is at high risk of major infectious diseases, including: food

or waterborne diseases: bacterial and protozoal diarrhoea, hepatitis A,typhoid fever

and viral haemorrhagic fevers. Also there are major challenges of zoonotic diseases

such as brucellosis whose epidemiology remains unquantified.

States have variable health profiles and epidemiological challenges depending on

infrastructure, geographical and socioeconomic determinants. For example, there is

a high burden of neglected tropical diseases including Leishmaniasis and

Schistosomiasis, mainly in Gedaref and Gezira states respectively.

Annually, Sudan faces an outbreak of meningococcal meningitis mainly by Neisseria

meningitides type A, and recently type W135 within the western states, with previous

history of major outbreak of CSM in 1998 which resulted in around 33000 cases and

3000 deaths. Acute watery diarrhoea outbreaks have been occurring annually.

During the last five years, the country experienced outbreaks of cholera, Rift Valley

fever and hepatitis, with high endemicity of malaria, enteric fever, dysentery and

other infectious diseases (including Dengue fever in eastern Sudan). More than 900

deaths were reported in 2006-2007 during the outbreaks of cholera, meningitis and

Rift Valley Fever.

An outbreak of viral hemorrhagic fever was reported in the western part of south

Kordofan state during October – November 2008. A total of 33 cases, including 14

deaths, were reported from the area during the mentioned period. Also, a dual

outbreak of dengue fever and hepatitis was reported in Red Sea State that resulted

in more than 500 cases including 39 deaths.

An outbreak of viral hemorrhagic fever was reported in the western part of south

Kordofan state during October – November 2008. A total of 33 cases, including 14

deaths, were reported from the area during the mentioned period. Also, a dual

outbreak of dengue fever and hepatitis was reported in Red Sea State that resulted

in more than 500 cases including 39 deaths.

Current sentinel surveillance reporting only covers 22 diseases and needs to be

reviewed on the basis of clear criteria an d processes to include new and emergind

diseases (Table 1). There are some important diseases that are not on the

notification list like brucellosis and visceral leishmaniasis. Othewre diseases need to

1

IHR 2005 Sudan report 2010

15


be re-classified from list B to List A. These are diseases under

eradication/notification like measles to synchronise with the disease control

programmes. Occasionally disease programmes information

(possible/probable/confirmed cases) is not identical or synchronous with the

suspected cases notified under sentinel surveillance (partly due to different case

definitions and partly due to sentinel (incomplete) notification.

There is only limited data on non-infectious PHEIC which historically were led by

non-health agencies (localities and Nuclear authority). Examples of PHEICs of

interest are related to agricultural management and safety of pesticides, industrial

disposal of chemicals, other waste management, safety of water supplies, petroleum

industry incidents, airport incidents including the effects of air pollution, noise and

accidents, nuclear energy project, etc. As the department does not historically

receive this information, it is difficult to assess the risk and magnitude of PHEIC;

hence the relevance of this strategy to IHR implementation.

Table 1: List of the Diseases Under Surveillance in the Epidemiology Department as of 2010

List A List B

1. Acute Watery Diarrhoea

2. Neonatal Tetanus

3. Hemorrhagic Fevers

4. Acute Flaccid Paralysis

5. Yellow Fever

6. Diphtheria

7. Epidemic Plague

1. Epidemic Typhus Fever

2. Meningitis

3. Viral Hepatitis

4. Malaria

5. Measles

6. Whooping Cough

7. Typhoid Fever

8. Anthrax

9. Food poisoning

10. Relapsing Fever

11. Adult Tetanus

12. Tuberculosis (T.B)

13. Rabies

14. Guinea Worm

15. Dysentery

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3.2 Policy context The policy for Disease Surveillance and Response is currently under development.

Through the policy, the department are mandated with early preparedness and

response (EPR) and mechanisms to implement the EPR elements of IHR 2005. The

contribution of surveillance to disease control programmes is relevant to the

Millennium Development Goals (particularly MDG6 and 7)

The policy supports the establishment of a national integrated disease surveillance

system (IDSS). IDSS promotes rational use of resources by reorganization of

common surveillance activities from clinical and laboratory sources, and includes

surveillance of food and water. The policy also requires quality assurance

mechanisms in place both for routine surveillance and for the role of Public Health

labs. The policy in this respect will require other departments to undertake their

collaborative role in food, water and vector surveillance.

The policy will also outline the obligatory duty of all the health facilities to notify

immediately any suspected case of list A, and other unusual/new/emerging disease

of concern or outbreak patterns. Procedures to include diseases in List A or List B

notifiable diseases will also be clarified in the policy.

The policy enables integration and coordination within and across sectors for

outbreak &/or incident investigation and response. Collaboration and coordination

with other sectors is key.

Other elements within the policy cover implementation of IHR 2005 in Sudan, and

the response to PHEIC, communication and notification of outbreaks and incidents

affecting national security, confidentiality and reviewing/enabling legislation with

regard to separation of South Sudan, with regard to IHR compliance, and with regard

to decentralisation policy, lines of accountability and the different structures in States

and Federal MoH.

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3.3 Structure, Function and Resources (FMoH Dept)

3.3.1 Department Structure as of 2010:

The department structure is based on historic functions (below) and will require

strategic reorganisation in light of IHR functions. The suggested (new) organisational

structure is recommended in the latter chapters of the strategy (Chapter 7).

3.3.2 Function of each unit

1. Surveillance Unit: data collection, data analysis, presentation and sharing of

information with stakeholders, supervision of sentinel sites, preparing daily,

weekly and annual reports of disease surveillance. training of surveillance team

members (i.e. registrars and members of surveillance units in the states with a

role in the annual expansion of sites). The annual expansion of sites was initiated

recently and will continue as per phased, planned approach, and includes the

private sector and other health facilities of Ministries of Interior and Defence.

2. Disease Control Unit (which covers the Outbreak Response function):

preparedness for seasonal outbreaks (e.g. CSM, VHF, Acute Watery Diarrhoea,

Viral Hepatitis), development of SOPs, development and/or facilitation of the

outbreak investigation teams and rapid response teams, leading the containment

period of the epidemics, preparation of the epidemic reports, Training of state and

federal rapid response teams, follow-up of health education materials with the

department of health promotion (unit provides information regarding targeted

population and behaviours, and how best to convey the message: via billboards,

media, etc..), follow-up of case management issues with the curative health

department (i.e. establishment and monitoring of isolation centres and drug

provision). Securing buffer stocks for the expected epidemics.

Directorate of Public Health and Emergency

Department of Epidemiology and Zoonotic Disease

Surveillance Unit

Disease Control Unit

Health Promotion

Planning and M&E

Unit

Training and Capacity Building

Zoonotic Diseases

Unit

International Vaccination

Unit

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3. Zoonosis Unit: main function is to co-ordinate between the Epidemiology

Department and the Ministry of Animal Resources (MoAR). Specific functions

include: provide technical support to both the Epidemiology Department and the

MoAR in mapping the distribution and calculating the burden of zoonotic diseases

in Sudan, pool information and serve as a reference point for all data concerning

zoonotic diseases, surveillance of zoonotic diseases (this function is to be

incorporated within integrated surveillance as part of clarifying the criteria for

inclusion onto the list of diseases), facilitating training of zoonotic diseases‟

surveillance personnel in health and veterinary sectors, participating in response

to zoonotic disease epidemics.

4. Planning Unit:

Main functions are planning (including developing guidelines, SOPs and

preparation of training modules); and also to develop the M&E function and

research functions which are not active yet. Current fire fighting approach for

outbreaks overtakes planning and projects tend to be dropped without notice.

5. International Vaccination Unit:

Main functions are delivery of international vaccinations and certification in line

with IHR. All states were carrying out vaccination activities semi independently

before 2004. To ensure compliance with IHR 2005, ministerial decree was issued

to unify vaccination procurement system and operation processes nation-wide.

Currently there are 28 centers for international vaccination covering the northern

states. Vaccinations covered include Yellow Fever and Meningitis. This provision

role is not in line with the early preparedness and response role of the

department. It is suggested that this function can be delivered more effectively in

another setting e.g. through the Expanded programme of Immunisation (to make

use of procurement and cold chain facilities) or as part of the IHR responsibilities

in Ports & Quarantine dept. Arrangements for transfer of this function outside the

department should ensure continued compliance with IHR and logistics.

3.3.3 Gaps - Functions not currently covered (as of 2010):

6. International Health Regulations non-infectious hazards:

These are not fully functional yet. A baseline assessment against the IHR 2005

was completed in Sep 2010. This recommended strengthening epidemiology and

zoonotic disease surveillance in the country, and that „Integrated disease

surveillance‟ as well as decentralized system is highly recommended. The list of

priority diseases should be revised and broadened to include other events to be

consistent with IHR 2005 requirement; the expansion of the list would allow

access to data on other hazards such as chemical and radio-nuclear events

collected by the respective specialized ministries or departments. Decentralised

system would ensure rapid and appropriate deployment of response teams to the

affected areas during outbreaks or occurrence of IHR-related events. The

development and “testing” of all-hazards response plans, with special

19


consideration of IHR-specific components, should be budgeted and funded. New

channels of communication should be opened with other ministries or related

institutions. The collaborative activities cover the whole realm of risk assessment,

development of appropriate preparedness plans, surveillance and response

activities.

7. Ports of Entry and Quarantine liaison:

With the establishment of a new Port of Entry and Quarantine department, and

while the remit of surveillance, preparedness and response in ports has been

taken out of the department, there remains the requirement to liaise with the new

dept. IHR baseline assessment recommended the need to establish and

formalize a coordinating, supervisory and communication mechanism between

Points of Entry Authorities.

3.3.4 Staffing in the department

The variability in staffing and qualifications at State level is demonstrated in the

table below. This also shows the high turnover of staff with more than half the

staff in post for less than 5 years, and 1 in 5 for less than 1 year. This is

particularly exacerbated in the FMOH where most staff are relatively new in post.

Table 2. Staffing in Epidemiology depts. at Federal and some States.

State School/

diploma

BSc Higher

Diploma

MSc Higher

degree

Total

staff

Staff < 5

years

Staff

<1 year

Federal MoH 1 12 0 10 1 24 18 10

Kassala 1 5 2 4 0 12 5 2

N Darfur 0 6 0 0 0 6 4 0

Sennar 0 3 0 1 0 4 3 1

W Darfur 0 2 0 0 0 2 2 0

White Nile 0 5 0 1 0 6 3 1

River Nile 3 3 1 1 0 8 4 1

S Darfur 4 8 0 0 0 12 7 1

Khartoum 1 2 0 1 1 5 2 1

Red Sea 2 1 0 1 0 4 2 0

Blue Nile 0 3 3 0 0 6 Missing info

Northern 1 2 1 0 0 4 Missing info

Total 13 47 7 18 2 87 >47 >16

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3.3.5 Analysis of budgets2

Budgetary spend on Epidemiology department functions was 4,307,700 SDG in

2010 ($1.66million according to official transfer rate in December 2010 of

$1=2.6SDG). This represents 83% of the planned budget to be spent in 2010.

Over a third of this budget (1,509,200 SDG; $580,500; 35% of the budget) was spent

reactively in response to outbreaks in viral hepatitis, acute watery diarrhoea and

haemorrhagic fever. It is worth noting that outbreak response can be really

expensive which justifies a focus on early preparedness and prevention. For

example, in the Rift Valley Fever outbreak in 2007-08, total monetary spend

exceeded 18,900,000 SDG (over $7million).

Over 60% of the 2010 spend (2,634,200 SDG; $1million) was spent on surveillance

activities including capacity building and equipment, but the largest component by far

was expansion of sentinel sites. This has implications for the development of

infrastructure of the whole network which is likely to be expensive in the short term

but will reap benefits in the longer term by reducing the impact and cost of

outbreaks.

Developing staff capacity in rapid response and supervision activities incurred a cost

of 119,300 SDG in 2010 ($46,000; 3%). Zoonotic disease EPR activities incurred a

cost of 16,000 SDG ($6000) – as this unit was newly introduced and activities not

fully operational. It is likely that spend on zoonotic disease will require more

emphasis, particularly as new and emerging diseases are increasingly of zoonotic

origin. Similarly spend on planning was 27,000 SDG in 2010 ($10,000) and as this is

the least emphasised unit in the department, further resources are needed to

establish planning and the evidence base functions.

2 Department Financial report 2010. This analysis excludes the Ports and Quarantine function which has now

separated out into its own department.

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3.4 Strategic relationships In the current Federal MoH structure, there are core functions related to IHR

implementation that are outside the department including Emergency Humanitarian

Action (emergency and incident response), Ports & Quarantine (securing points of

entry) and PH labs (accredited facilities for disease confirmation). Significant liaison

is required between these departments for IHR implementation as well as review of

standing committees and liaison mechanisms.

To undertake the core functions, there are considerable cross-cutting activities with

other departments, and the hub and spoke relationship with States needs to be

strengthened.

3.4.1 Cross-Cutting Activities with other FMoH departments

1- Surveillance and response of the following diseases:

a. TB (with national TB program)

b. Malaria (With Malaria program)

c. Acute Flaccid paralysis (with EPI)

d. Neonatal Tetanus(with EPI)

e. Diphtheria(with EPI)

f. Measles(with EPI)

g. Whooping Cough(with EPI)

h. Guinea Worm (With Guinea Worm Program)

2- Surveillance of non-infectious hazards (chemical, physical and others): is

responsibility of the department according to the IHR, but is not done now.

The job is carried out by other departments and needs to be coordinated with

the Epi. Dep. Eg NCD unit on safety promotion and injury prevention

3- Surveillance and response of Zoonotic diseases (Influenza, Rabies, Brucella,

hemorrhagic fevers and others): this activity is to be well coordinated with the

ministry of Animal resources and Fisheries.

4- Surveillance of the diseases in outpatients departments: this is done by the

Center of Statistics, FMoH (routine informations system) which collect data on

all the diseases including data on the notifiable diseases.

5- Water and environmental surveillance: responsibility of environmental health

department who cover food and water safety, environmental safety, sanitation

and other environmental contaminants. A coordination mechanism should be

established. Integration of data from these systems within the surveillance

system of the department.

6- Epidemiological surveys for non-communicable diseases and routine

information system strengthening. The Epidemiology dept needs to consider

its role in developing these systems eg inter-epidemic surveys.

22


7- Procurement of drugs, vaccines and other medical supplies: needs

coordination with the WHO, UNICEF, curative medicine department and

central medical stores.

8- Set-up of isolation treatment centers, preparation of guidelines for case

management and training of medical personnel: this job is carried out by the

department in case of outbreaks. It should be coordinated with the curative

medicine department. Reports on these activities in the early preparedness

should be shared between the 2 departments.

9- Development of IEC materials and distribution to the targeted audience: in

collaboration with the health promotion department and UNICEF.

10- Vector control activities: conducted by the Integrated Vector control

department.

11- Water chlorination, Food safety and Environmental sanitation: the

environmental health department.

12- Response to the mass events like natural disasters and Influenza pandemic :

Civil defense and other emergency committees are involved in this issue.

13- Ports and quarantine dept: capacity building and coordination. Notification

from ports and quarantine to become surveillance sites. New sites to be

established on new border.

14- National PH lab: requires capacity building and accreditation to level 3 and 4.

Current issues regarding administrative follow up for outbreak confirmation.

Integrated disease surveillance requires lab based notifications and rapid

response to lab reports. This is the role of health facility labs in surveillance

facilities and the seven regional PH labs; the roles of these spoke facilities

needs to be developed and enhanced.

3.4.2 Epidemiology departments in States

States have variable structures, and staff in Epidemiology departments may have

other commitments. This variability partly contributes to variability of resourcing

between States and some states have high staff turnover. States human resource

issues are dominated by incomplete organisational structures, key staff covering

more than one role, lack of cascade training and some States have expressed

inequity in access to training opportunities.

States do have fair availability of logistical power, but not sufficiently guaranteed as

in most cases, priority is given to outbreak control rather than early preparedness

and prevention. Rapid response teams are mandated in most states but again there

is variability in resourcing and capacity.

Federal assistance is still controlled centrally (rather than delegated); training is

supported by the FMoH and available as basic, refreshment and advanced.

Supervision and support are available from the Federal Epidemiology department

mainly during outbreaks. Regular communication with FMoH, feedback and

23


supportive supervision requires strengthening, with opportunities for State to State

peer support e.g. arrangements between neighbouring States. States have

articulated their need for local public health labs that are accredited for outbreak

diagnosis.

The variability in staff is demonstrated in Table 2 above. A further gap analysis is

proposed for the infrastructure available in States against the standards expected at

each level. This should build on the expansion plan for surveillance, and should

demonstrate the resources gap particularly for early preparedness and resources for

rapid response.

3.4.3 Epidemiology departments in localities

At locality level, activities are reportedly better integrated than at State or Federal

level. However the multiplicities of reporting mechanisms (and accountability) can

over-burden staff at locality and health facility levels. Double reporting and

sometimes triple reporting to programmes, health information and surveillance

system results in multiple reporting lines and lines of accountability.

Outbreak thresholds at this level are not clear to staff (or have not been defined) and

there is lack of clarity as to whether action should be based on clinical judgment or

lab confirmation. Expansion of surveillance sites is needed to be informed by

geographical and epidemiological understanding of local communities.

While there is fair availability of logistical power at State level, this is not reflected

operationally at localities where the variability is even greater. Even where rapid

response teams are available and named, some logistical issues remain for lack of

resources. This particularly affects prevention and early preparedness work e.g.

rapid response to outbreaks in relatively inaccessible areas, staff and materials for

vector control.

Long term partnerships with NGOs and communities cannot be sustained except for

one-off campaigns. Most localities have the local contacts but do not activate these

routinely. Still there are examples of good community mobilisation in some localities

and partnerships sustained through seasonal local emergency committees and

partnerships with local NGOs like the red Crescent and community leaders. Local

committee structures in localities generally do approach locality offices for

notification of unusual disease occurrence.

Also on the positive side, many staff at this locality level are local staff and tend to

remain for a long time. The need for capacity building and continuous professional

development cannot be overlooked; as at this level, staff are the first responders and

front line of prevention.

24


3.4.5 External stakeholders and partnerships

There are a number of relationships that exist for the Epidemiology department with

bodies outside MOH.

1- WHO, UNICEF: provide technical and financial support to the department.

Their interest is in building national capacity both at federal and state level.

They also liaise with the international community and are key in implementing

IHR 2005 notification, recommendations and follow-up actions.

2- Ministry of Animal Resources and Fisheries: deal with the animal side of

Zoonotic diseases. A mechanism of coordination and collaboration is in place,

but the way priorities are identified is different so a dichotomy in speed of

response. There is a need to agree the priority areas of action.

3- Civil Defense: play the role of command in natural disasters events and in

PHEIC also. Relationships with health and mechanisms of coordination within

the health sector need to be clarified.

4- National Security: dealing with national security issues of outbreaks, including

flows of information and declaration of incidents or outbreaks. Hence will have

a role in IHR notifications.

5- Police and Armed Forces health services: have a role in incident/outbreak

response within the catchment of their health facilities and also need to be

included in the expansion of surveillance sites

6- Private sector: Private health facilities also do not routinely notify

7- Mass media: are partners in health promotion activities and communicating

with the public during an outbreak or incident.

8- Communities and NGOs are not engaged with the Epidemiology department

as routine. In the event of a campaign or for rapid response, localities do

engage with the local networks.

9- Politicians and senior government: interested in issues of national security,

cost and will need to see the economic argument for proactive resourcing for

better infrastructure and early preparedness as a way to prevent outbreaks

and reduce costs of outbreaks.

25


3.5 Summary of situation analysis (SWOT) The Federal Epidemiology department demonstrates that it has the following

characteristics:

1. STRENGTHS: Distinctive competency in outbreak management. The department has good experience of managing outbreaks and the range of diseases. Great team work is apparent particularly in event of outbreaks. Strategic development is needed to build on this competency to handle all PHEIC (and local concern) in particular incidents that are related to non-infectious hazards.

2. WEAKNESSES: There are operational barriers in surveillance and outbreak control. Other than resource issues, there are occasional delays in reporting from the states, no adequate disease mapping, notifications list needs revising, and sentinel surveillance might miss outbreaks. There are administrative delays in lab confirmation of cases during outbreaks.

3. OPPORTUNITIES: With respect to the considerable cross-cutting issues, there is lack of clarity in relationships with partners and stakeholders; and the department would benefit from strategic work in this respect to clarify roles and responsibilities. This is even the more so with respect to the surveillance function and disease control activities in an outbreak (role of disease programmes, role of States, and collaboration with external stakeholders outside MOH, communities and local NGOs)

4. THREATS: Access to resources is limited in relation to actual resource needed. The department does not have sufficient resources to run a safe service. While good at fire-fighting, the attention forcedly given to outbreak management detracts from the resource available to important but not urgent priorities, and hence the long term sustainability of the department. The department is now within a vicious cycle of overdrive with little time for documentation and backup processes. As this reduces efficiency and effectiveness, there is a higher propensity for significant events to go unnoticed. In this climate, attracting further resource needs to be on the basis of strategic planning rather than on the basis of reactive allocation.

5. “Fire fighting” approach to work dominates and delays other departmental activities. The department acknowledge that StEpi should enable a strategic shift.

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4. The Strategic shift

4.1 Strategic issues While the Epidemiology departments at Federal, State and locality levels do have

strengths in some areas, the following operational and strategic developments are

needed in the next five years.

1) Meet minimum standards in day to day work within the Epidemiology network (Federal and States); also to clarify roles and responsibilities with stakeholders and partners in each specific function.

2) Transform the network into its vision of excellence and proactivity, alongside

sufficient capacity and resource enablers. A strategic shift is needed to take place

urgently.

While the Federal department have already taken steps towards this shift, StEpi

reinforces and reaffirms the direction of travel and as a communication tool which

articulates the requirements and enablers to make this happen.

Strategic shift:

From reactive to proactive,

From fragmented & sentinel surveillance to comprehensive integrated surveillance,

From central response to decentralised response,

From disease focused to IHR focused ( PHEIC).

This strategy assumes that the policy currently under development will enable the

strategic objectives and workstreams described here.

27


4.2 Strategic Objectives and Strategies 1. Strategic Objective (Transformational): To transform the network into its vision of

excellence with efficient Epidemiology departments at all levels that can forecast and

control all public health emergencies of concern.

1.1 Strengthen States to undertake their decentralised functions

1.2 Develop staff competence at State and Federal levels

1.3 Develop the network for mutual support across levels

1.4 Develop evidence to support decision making

1.5 Develop strategic partnerships to enable the transformation

2. Strategic Objective (Transactional): To improve day to day work of early

preparedness, early detection and containment of outbreaks/incidents.

2.1 Establish an integrated surveillance system to detect all types of PHEIC

2.2 Emphasise systems of early preparedness that enable efficient

management of logistics

2.3 Set up mechanisms to respond to all PHEIC as per IHR implementation

2.4 Undertake rapid response to outbreaks and incidents

2.5 Strengthen liaison functions with P&Q for IHR and zoonotic diseases

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4.3 Overview of Strategic Plan of the Epidemiology Department, FMOH

(StEpi) 2012- 2016

25yr National Health Policy

IHR 2005, draft Policy for Epidemiology dept, MDGs

Five year Strategy for Health (2012-16)

Public Health Act, other legislations, decentralisation

StEpi

Transformational work

Transactional work

Strengthening States and localities: Attracting resources

Early preparedness and operational planning (stocks, supervision, technical/ financial support)

Developing staff: Capacity building and staffing (recruiting, , training, SOPs and job descriptions)

Responding to all PHEIC as per International Health Regulations (including non-infectious hazards)

Developing the network: Peer and mutual support within the network (inter-State peer support, FMoH – States supervision)

Outbreak/Incident control (roles & responsibilities, logistics and resource management)

Developing evidence: Evidence base function: Forecasting, operational research, M&E

Integrated Surveillance (clinical surveillance, labs, environmental, water, vector food, air) and increase coverage of sentinel sites

Developing strategic partnerships with other depts., partners and communities

Port health liaison and International vaccination Zoonotic Disease liaison

29


5. Transformational Planning


Problem statement:

Insufficient Resources: manpower (number/qualifications), money, technology

and materials are all seriously lacking.

Key Result Areas:

5.1.1. Minimum standards have been set in place for staff and infrastructure at

State and locality levels (e.g. to include minimum requirements for

skills/experience in technical skill and leadership, surveillance, rapid

response teams)

5.1.2. Staffing plans and succession planning in place to address sustainability.

5.1.3. Resource based on evidence????, improved documentation and back-up

processes are developed within Epidemiology departments in FMOH,

States and Localities.

5.1.4. The states‟ and localities‟ departments are well equipped by the right

technologies and materials.

5.1.5. Adequate resources available for early preparedness and response.

Products:

5.1.1.1. Revision and completion of the organisational structure of Epidemiology

departments in States and Localities

5.1.1.2. Revision and completion of the basic infrastructure standards (what

standards??)of Epidemiology departments in States and Localities

5.1.1.3. Undertake gap analysis at state level against EPR/IHR standards (do we

have such standards available, agreed upon and endorsed??)

5.1.1.4. Develop departmental guidelines what do we mean by departmental?,

protocols and SOPs for States and Localities

5.1.2.1. Define the specific roles and skills sets needed to execute the EPR/IHR

functions at state and locality levels i think it can be combined with the

5.1.1.1 as the structure organogram should include job description and

required competencies!

5.1.2.2. Determine if staff is available at state and locality levels looks as if we

don‟t know our staff! I think it is better to rephrase, like develop and

implement human resource management and development plan

5.1.2.3. Secure and sustain the needed staff at state and locality levels

5.1.2.4. Identify training and coaching needs and plans

30


5.1.3.1. Improving documentation and back-up processes in the states and

locality epidemiology departments evidence based resources need

separate product???

5.1.4.1. Improve working environment

5.1.5.1. Improving advocacy and proposal writing skills

5.1.5.2. Efficient management of available resources

31


5.2 Develop Staff competence at Federal level

Problem statement:

Insufficient human resources (number and qualification).

No departmental quality management tools.

Key Result Areas:

5.2.1. The minimum standards have been set for right skills/experience in

technical skills, leadership, surveillance and response at the national

level.

5.2.2. The units‟ structures/organization and staff job descriptions are clarified.

5.2.3. Staffing plans and succession planning are in place to address

sustainability.

5.2.4. Departmental quality management tools are developed and implemented.

Products:

5.2.1.1. Revision and completion of the standards of Epidemiology department

capacity at the national level.

5.2.1.2. Undertake gap analysis at the national level against EPR/IHR standards

5.2.2.1. Revision and completion of the organisational structure of Epidemiology

department at the national level.

5.2.2.2. Clarify the job description for all national epidemiology department

functions.

5.2.3.1. Define the specific roles and skill sets needed to execute the EPR/IHR

functions at national level.

5.2.3.2. Determine if staff is available at the national level.

5.2.3.3. Secure and sustain the needed staff at the national level.

5.2.3.4. Identify training and coaching needs and plans.

5.2.4.1. Develop and implement departmental guidelines, protocols and SOPs for

the national level.

32



Problem statement:

States are at variable levels of skill, resource and staffing

Supportive supervision needs to be strengthened (FMOH – State)

State-State interaction is not systematised

Laboratories at national, state, locality and health facilities are not well

established

Key Result Areas:

5.3.1. Agreed structure and guidelines for supervision is developed

5.3.2. Inter-State mentorship and peer support is established

5.3.3. Public Health reference labs in States and centrally are accredited with

appropriate specialisation of state labs to cover certain diseases for the

network

5.3.4. Laboratories in surveillance facilities are strengthened

Products:

5.3.1.1. Supportive supervision guidelines, SOPs and manuals are developed at

all levels

5.3.1.2. Supportive supervision plans are developed at all levels

5.3.2.1. Coordination and collaboration, plus sharing of experience between the

states

5.3.2.2. Peer supervisors from state level to be involved in supervision alongside

federal staff

5.3.2.3. Learning sets for State and FMoH staff are developed for State-State

learning, based around evaluations from previous outbreaks/incidents

5.3.3.1. A lab network is developed based on a hub and spoke model

5.3.3.2. Accreditation mechanisms for PH labs in national and States and locality

levels

5.3.4.1. A quality control system is developed to strength the health facilities labs.

5.3.4.2. Standards, protocols, guidelines and SOPs are developed for the health

facilities labs

5.3.4.3. Develop well structured sample collection, transportation and processing

system

33


5.4 Develop Evidence to support decision making:

Problem statement:

Current activities are not necessarily directed by operational research results

and /or the available, local, national or international scientific evidence body.

Key Result Areas:

5.4.1. Evidence produced from better use of information, research and

experience

5.4.2. Strengthening of the M&E capacity within the department and at state

level

Products:

5.4.1.1. Documentation of accumulative previous experiences in outbreak

response in the country

5.4.1.2. Prospective documentation of incidents/outbreaks

5.4.1.3. Training on generation and use of evidence

5.4.1.4. Undertake epidemiological research to identify current, major, „hidden

epidemics‟ and other significant public health hazards

5.4.1.5. Operational research should be undertaken to clarify barriers to the key

functions of the department.

5.4.1.6. Conduct Regular audit of processes

5.4.1.7. Produce departmental publications in local and international literature

5.4.2.1. Develop a well functioning M&E system at all levels

5.4.2.2. M&E procedures should accompany all departmental activities at all

levels

34


5.5 Develop Strategic partnerships to enable the transformation:

Problem statement:

Roles and responsibilities of the various stakeholders and partners are not

defined

Communities in particular are not involved routinely

Key Result Areas:

5.5.1. Permanent & effective coordination mechanisms are established at all

levels

5.5.2. Community partnerships including community-based research and

interventions are initiated

Products:

5.5.1.1. Formulation of standing committees at all levels

5.5.1.2. Clarify roles and responsibilities of different stakeholders at all levels

5.5.1.3. Establishment of information sharing mechanisms between all

stakeholders

5.5.2.1. Design and introduce a community-directed interventions (CDI) at all

levels

35


6. Transactional Planning

6.1 Establish an Integrated Surveillance system

Problem statement:

Problems with respect to coverage, timeliness, analytical capacity and lab

confirmation of cases.

Not compliant with IHR as confined to disease surveillance onl.

Key Result Areas:

6.1.1. Protocols, guidelines and SOPs for integrated disease surveillance

system are developed and implemented

6.1.2. The quality, sensitivity, coverage and timeliness of surveillance system

are improved.

6.1.3. Surveillance for PHEIC is implemented at all levels.

6.1.4. Information on food /water safety and vector surveillance are shared with

other departments.

Products:

6.1.1.1. Inclusion of vertical programmes‟ surveillance systems in the integrated

surveillance system

6.1.1.2. Develop surveillance guidelines for diseases under eradication

6.1.2.1. Revision of the current disease notification list

6.1.2.2. Sentinel-sites‟ reporting system is shifted to cover all health facilities by

2015

6.1.2.3. Define and implement notification policy from Police, Armed Forces and

Private health facilities.

6.1.2.4. Assess the sensitivity of the current surveillance indicators and tools, and

test the use of statistical process control.

6.1.2.5. Expansion, revision and improvement of the mobile phone

communication network

6.1.2.6. Web based electronic surveillance is functioning at all levels.

6.1.2.7. Ensuring the completeness of reporting from sentinel sites, including

complete case-based reporting.

6.1.2.8. Develop interaction mechanisms between the public health laboratory

services, the other laboratory sectors and the surveillance system.

6.1.3.1. Develop and implement guidelines for PHEIC surveillance

6.1.4.1. Develop and implement guidelines on water, food and vector surveillance

36


6.2 Emphasise systems of early preparedness and manage logistics

Problem statement:

The logistical management system is not well defined and functioning.

Early preparedness functions are not assigned for a defined unit.

Risk reduction functions are not in place.

Forecasting ability is very poor.

Key Result Areas:

6.2.1. The department‟s logistical management system is well defined and

functioning

6.2.2. Early preparedness for incidents and disease outbreak is strengthened

and implemented

6.2.3. Risk reduction system is well established

6.2.4. Enhanced forecasting ability through surveillance function

Products:

6.2.1.1. Develop anticipation of demand system for all materials and supplies.

6.2.1.2. Develop efficient transportation system using batches of a size and

frequency.

6.2.1.3. Develop of stock management tools Pre-positioning of supplies based on

proper need estimates.

6.2.1.4. Improve the Storage capacity at all levels.

6.2.2.1. Activation of early preparedness standing committees at all levels for

incident/ disease outbreak.

6.2.2.2. Preparation of early preparedness plans for incident/ disease outbreak.

6.2.2.3. Expansion, assessment and improvement of the communication network.

6.2.3.1. Preparation of a risk assessment models

6.2.3.2. Implement vulnerability reduction measures.

6.2.4.1. Develop forecasting system based on the integrated surveillance system

37


6.3 Respond to all PHEIC

Problem statement:

The department is currently more concerned with disease control as opposed

to risk reduction.

Developmental needs identified with respect to IHR compliance.

Key Result Areas:

6.3.1. Detailed action plan for implementation of IHR 2005 is incorporated into

annual planning processes and M&E

6.3.2. Awareness and concern about emerging public health hazards, such as

chemical, nuclear, and other biohazards

Products:

6.3.1.1. Adopt recommendations of IHR baseline assessment report.

6.3.1.2. Continue dialogue with all relevant stakeholders and strengthen functions

and channels of communication

6.3.1.3. Develop risk profiles and maps of potential non-infectious hazards and

emergencies in each State

6.3.1.4. Desk mechanism extended from diseases to include hazards and

incidents.

38


6.4 Undertake rapid response to Outbreak/Incident Control

Problem statement:

Fire-fighting approach to outbreak response.

Incident response not currently undertaken.

Epidemiology department role in PHEIC/incident control is not recognised

under the current FMoH structure as there is considerable overlap with

Emergency Humanitarian Action Department.

Key Result Areas:

6.4.1. Leadership of incidents and outbreaks is taken by the department

6.4.2. Clear criteria for involvement of federal dept in outbreak/incident

response with the existence of State RRTs

Products:

6.4.1.1. Clarify and define the role of the department during disease outbreaks

regarding the individual staff roles and the roles of others

6.4.1.2. Clarify role of disease programmes in disease management and avoid

duplication.

6.4.1.3. Define the role of the department during PHEIC/incident control.

6.4.1.4. Joint simulation exercises and outbreak debriefs involving all partners

6.4.2.1. Revise the state capacities to respond to outbreaks and incidents

6.4.2.2. Prepare a capacity building plans for the states

39


6.5 Strengthen liaison functions (Zoonotic Disease, Ports &

Quarantine)

Problem statement:

Ports & Quarantine are a new department with core IHR functions so liaison is

needed

Zoonotic disease unit is a relatively new unit within the Epidemiology

Department.

Key Result Areas:

6.5.1. The liaison with the Ports and Quarantine is strengthened

6.5.2. Clear working plan for the Zoonotic disease unit, focusing on liaison

(advocacy and coordination)

Products:

6.5.1.1. Ports & Quarantine facilities to become surveillance sites

6.5.1.2. To explore other liaison requirements for Ports & Quarantine

6.5.2.1. Review status of zoonotic diseases in Sudan and establish a baseline

6.5.2.2. Collaborate with other units within the department to establish zoonotic

disease surveillance and outbreak control as integral part of other units

6.5.2.3. Institute procedures for inclusion of new and emerging diseases in the

surveillance list of diseases

6.5.2.4. Raise awareness of zoonosis inside the ministry of health and among its

partners

6.5.2.5. Strength the role of senior level joint Steering group between MoH and

MoAR

40


7. Enablers

7.1 Modifying organisational structure o Rename surveillance unit as integrated surveillance unit

o Liaison with programmes and Health Information System to be

undertaken by integrated surveillance unit

o Port health liaison function to be undertaken by integrated surveillance

unit

o M&E/ Evidence based functions to be developed by planning unit

o SOPs and Job descriptions to be developed by planning unit

o Vaccinations to move to alternative provider

o States and Federal lines of accountability to be clarified in policy

o RRTs to be set up in States and localities to be overseen by Outbreak

response unit, and with standard minimum staffing and skills

requirements

o Staff development plans at all levels to be developed by planning unit

o Set up a new incident response unit or include these in the current

disease control unit and rename it the PHEIC response unit

o EHA and Epidemiology department to be merged or clear lines of

responsibility defined in the policy document. If merged, EHA to

become part of PHEIC response unit or establish itself separately as

the incident response unit

o Public Health labs network to be strengthened as a key partner to

Epidemiology department

o Desk mechanism to manage specific diseases modelled on the current

Zoonotic disease unit. Can possibly include Zoonotic disease unit

within a new structure called disease liaison unit (this separates out the

surveillance and response activities to go within the respective units;

and minimises duplication)

41


7.2 Attracting Resources needed to fill the gap o Staffing and resources gap analysis to be completed

o Procurement plan required to avail essential equipment for surveillance and RRTs at Federal, State and locality level (on the basis of agreed infrastructure standards)

o Advocacy to secure political will and financial commitment

o Financial business cases to justify early preparedness versus reactive

response

o Bidding for increased resources through research and improvement

projects

o Talent spotting and retention solutions for specialist staff

7.3 Change management models: Change management models that are recommended, include training on:

o Leadership skills development

o Force field analysis

o stake holders‟ influence diagram to influence stake holders,

o RA(S)CI model to clarify roles and responsibilities.

7.4 Enabling legislation o Constitute Standing committees for IHR implementation o Adopt recommendations of policy group and implement key policy

recommendations

o Establishing implementation mechanisms for legislation

o SOPs reflect roles and responsibilities in line with legislation/policy

7.5 Action Planning and M&E requirements

The 2011-2012 plan is attached in the Appendix.

Action plans will be developed that phase activities over the next five years of the

strategy. To ensure implementation of this Strategic Plan, the department will

develop annual action plans for 2012 to 2016 with M&E indicators.

Results based planning includes M&E indicators. The framework in the next chapter

utilises a grid to demonstrate the M&E indicators for the transformational and

transactional objectives and for the enablers. More specific indicators will be further

developed in action plans. A time plan that phases the strategy across the years is

also provided in Chapter 8.

42


8. M& E Framework and Time Plan (2012-2016)

M&E grid 2.1 Integrated surveillance system

2.2 Early preparedness and logistics

2.3 Response to all PHEIC

2.4 Rapid response to outbreaks/incidents

2.5 Liaison functions (P&Q and zoonotic diseases)

ENABLERS

1.1 Strengthen States % gap in number of surveillance sites against expansion plan

% gap against standard infrastructure, supplies, and transport

Standing committees at locality level

RRTs named and trained (standard of at least one per locality)

Standing committees at State level

Procurement and staffing plans in place for States and localities. SOPs in place

1.2 Develop Staff at State and Federal levels

Performance against training plan for new surveillance sites and refresher. State peer supervisors trained

Advocacy skills training undertaken

Training on risk profile and mapping

Simulation exercises and debriefs (eg every two years)

Staff placements and exchanges in place

FE(L)TP in place, and 3mth – 9mth modules. Change management /leadership training

1.3 Develop the network Annual supervisory visits to States in place with written feedback (Federal - State Supervision)

State to State shared logistics and cover for response?

Desk mechanism in place. Accreditation status of regional labs

PH lab network strengthened: % labs reporting from surveillance sites.

Staff placements and exchanges in place, including learning sets

Legislation/decentralisation enabled through ToR for State & Federal Standing Committees

1.4 Develop evidence % outbreaks detected through surveillance system. Early warning thresholds in place for all diseases under notification

Financial business cases to justify early preparedness

Risk profile and mapping undertaken for each State and locality

Documentation Eg Incident/outbreak reports published within 2mths of conclusion

Risk assessment for zoonotic disease and port health undertaken for each State

Operational researches (5 per year). Improvement and research project funds availed

1.5 Develop strategic partnerships

P&Q facilities reporting to surveillance plus other health providers (comprehensive surveillance)

Enhanced role of communities and local NGOs

Standing committees at

State and Federal level

Standing committees at State

and Federal level

Criteria in place for new disease control

programmes

Standing Committees ToR and MoUs signed clarifying respective roles/ responsibilities

43


TIME PLAN 2011 2012 2013 2014 2015 2016


i. Minimum standards for staff and infrastructure at State and locality levels

ii. Staffing plans and succession planning in place

iii. Improved documentation and back-up processes

iv. Improved working environment

v. Adequate resources during outbreaks.

5.2 Develop Staff competence at State and Federal levels

i. Departmental SOPs ii. Training programme, based on training needs‟

assessment

iii. Opportunities for scholarships and/or research


i. Agreed structure for supervision and peer supervisors from State level

ii. Inter-State mentorship and peer support

iii. Learning sets for State and FMoH staff

iv. Accredited regional PH reference labs and centrally

44


TIME PLAN 2011 2012 2013 2014 2015 2016

v. Labs in surveillance facilities strengthened

5.4 Develop Evidence to support decision making: i. Better use of information, research and experience

ii. Evidence based approaches (operational research)

iii. M&E capacity strengthened

iv. Documentation of accumulative experiences of incidents/outbreaks

5.5 Develop Strategic partnerships to enable the transformation: i. Permanent & effective coordination mechanisms (Standing committees)

ii. Simulation exercises and evaluations.

iii. Community partnerships initiated

6.1 Establish an Integrated Surveillance system

i. SOPs for diseases under eradication, roles of disease control programmes, and roles of the PH lab

ii. Web based electronic surveillance

iii. Comprehensive reporting in 2015

45


TIME PLAN 2011 2012 2013 2014 2015 2016

iv. Sensitivity of current surveillance improved (and use of statistical process control).

v. Revision of the current disease notification list

vi. Agreed criteria for placing a disease under list A or B

vii. Integrated surveillance for all PHEIC

viii. Laboratory protocol reviewed

ix. Food /water safety and vector surveillance availed from respective departments.

6.2 Emphasise systems of early preparedness and manage logistics

i. Early preparedness for incidents/outbreaks recognised as the responsibility of the department

ii. Logistics in place for early preparedness

iii. Pre-positioning of supplies. and stock management tools

iv. Enhanced forecasting ability through

surveillance function

6.3 Respond to all PHEIC

46


TIME PLAN 2011 2012 2013 2014 2015 2016

i. Detailed action plan for implementation of IHR 2005

ii. Awareness and concern about emerging public health hazards, such as chemical, nuclear, and other biohazards

6.4 Undertake rapid response to Outbreak/Incident Control

i. Leadership of incidents and outbreaks

ii. Clear criteria for involvement of federal dept in outbreak/incident response

iii. Joint simulation exercises and outbreak debriefs involving all partners

6.5 Strengthen liaison functions (Zoonotic Disease, Ports & Quarantine)

i. Safe transfer of international vaccinations to other provider

ii. P&Q to become surveillance sites

iii. Clear working plan for the Zoonotic disease unit

iv. Baseline for status of zoonotic diseases in Sudan

v. Senior level joint Steering group between MoH and MoAR.

47


Appendices

Appendix 1: Epidemiology dept plan for 2011 o 2011 plan

Epidemiology Department 2011 Interventional Logic

Overall Objective

The department of epidemiology is strategically moved to better perform its core functions, implementing the state-of-the-art technology, and building the capacity of the system.

Expected Results

Products

Activities

Activities Components

Institutional capacity of the Epidemiology Department at National and 15 states levels has developed towards the strategic shifting

Strategic Development

The Strategic Plan for the department is developed by end of March 2011

Department's transactional work document is available by 2011

1-days workshop on transactional work in January 2011

Department's transformational work is available by 2011

1-days workshop on transformational work with stakeholders in February 2011

48


by the end of 2011. Final draft strategic plan is available by 2011 Endorsement by the Undersecretary Council

The capacity of the staff of departments of epidemiology at national and 15 state levels is upgraded by end of 2011

MSc in Field Epidemiology is available for 30 employees from the national level and 15 states by 2011

Creation of curriculum and timeline by February 2011

Accreditation in coordination with PHI by March 2011

Selection of the candidates for the degree by May 2011

Training materials are revised and training workshops are organized regularly at national, 15 states and locality levels by 2011

New staff on surveillance has received training on surveillance by March 2011

Disease control staff has received training on disaster management by March 2011

Staff in FMoH and SMoHs is trained on Planning and M&E by September 2011

IHR compatiblity

The current situation regarding IHR is reviewed and implemention of IHR is initiated

IHR assessment report is revised by 2011

Re-analysis of the IHR assessment using new indicators

A new version of the report to be developed by February 2011

IHR implementation plan is prepared by 2011

A consultant to be hired for the implementation plan

A technical committee to be nominated to participate in the plan formation

Workshop for the adoption of the plan

IHR implementation plan is executed by 2011 The IHR implementation plan to be exucted according to the workshop recommendations

49


Strengthening of the current International Immunization Centers (IIC) by end of 2011

Development of a standard structure proposal for International Immunization Centers by January 2011

Supervisory visits to all International Immunization Centers by September 2011

Reopen the 2 closed IIC in Khartoum and Gaziera states by April 2011

Enhancement of the security of the International certificates and stamps by 2011

Creation of new highly-secured stamps

Enhanced security certificates from the Sudan Currency Printing Press

Implementation of security detection devices at the ports

M&E and Operational Research

Electronic M&E system is developed for the surveillance and response systems at the national level by 2011

Set up of electronic Data collection and Analysis by 2011

Prepare the proposal by February 2011

Implementation of the system by March 2011

Biannual M&E Meetings with SMoHs and stakeholders

Prepare a structure for the M&E meetings by February 2011

Operational Research unit is established at national level by 2011

Operational Research Proposal is available by 2011

To appoint a focal person for the operational research

50


By end of 2011 the

coverage and quality of

the surveillance system

is increased from 12%

to 30% of total health

facilities (not less than

60% population)

coverage).

Surveillance

The existing

surveillance and

response systems have

been strengthened at

national, state and local

levels by the end of

2011

SOPs & Guidelines are published by 2011

Finalization of the drafts by January 2011

Publicization to federal, state and locality levels by

March 2011

Coordination with stakeholders is improved by 2011

Bimonthly meetings with relevant partners and

stakeholders inside the FMoH

Monthly meetings with stakeholders outside the

FMoH

the national Data collection tools are improved by

2011

Update the format of daily and weekly notification

forms by January 2011

Set schedule for reporting by January 2011

Revision of Notifiable disease list by March 2011

the national Data reporting system are improved by

2011

Maintain the communication network by January

2011

Analyze data using STATA or EPI INFO instead of MS

Excel by April 2011

Establish weekly and monthly Bulletin by February

51


Provide essential materials for the sentinel sites by

February 2011

Competent supervisory system on the state

surveillance units is achieved by 2011

Revision of supervision materials by April 2011

Execution of 15 supervisory visits by November 2011

Electronic Surveillance

System is implemented

and functional in 15

states and 30 localities

by 2011

Finalization of the proposal by 2011 Publicize the manual to use the Electronic System

Execution of the pilot phase in Gazeira, Kassala and

North Kordofan by 2011

Distribution of Computers to the three states

Training of directors of epidemiological department

and the head surveillance unit at state level on ESS

Monitoring and Evaluation of Electronic Surveillance

system

Evaluation of the pilot phase and kick off of phase 2

by 2011

Surveillance Coverage is

expanded in all 15

states from 12% to 30%

of total health facilities

Introduction of Spatial Epidemiology in the

Surveillance system GIS mapping of the current sentinel sites by 2011

Addition of 1028 sentinel sites to the surveillance

network by 2011

Selection of the sentinel sites

Training of the staff

Preparation of communication facilitieis and material

52


needed

Evaluation of the newly added sentinel sites by 2011 Supervisory visits to the new sites (1024)

By end of 2011 the timely

and efficetivly response

towards seasonal outbreaks

has been ensured.

Disease Control

The response to frequent and

emerging outbreaks is more

timely and efficient by end of

2011

Apply Early Preparedness for

frequent outbreaks 2 months

before the expected outbreaks at

national, state and local levels by

2011

drugs and supplies are calculated according to the expected

need, prepositioned at state and locality levels by 2011

Health education massages are prepared, produced and

distributed to the state and locality levels by 2011

outbreak control cadres are trained (Basic & Refreshment)

all levels by 2011

Emergency Committees are formulated at all levels by 2011

Risk Mapping of the suspected outbreaks is conducted in all

states by end of 2011

Prepare Rapid Response Teams

(RRTs), equip and train them 1

months before the expected

outbreaks at national, state and

Formulation of Rapid Response Teams at all levels by 2011

Training of RRTs at all levels by end of 2011

53


local levels by 2011

Efficient and timely Outbreak

Control and Response for

expected outbreaks at national,

state and local levels by 2011

Proper Case management is ensured by 2011

Standardized Interventional measures are taken at all levels

by 2011

Final outbreak report is produced after each outbreak by

2011

Supplies and Buffer Stock

Software is implemented and

functional by 2011

Check the current status of the system by January 2011

Launch the pilot phase of the software by March 2011

Zoonotic Diseases

Surveillance and response of

Zoonotic diseases is upgraded

at all levels by 2011

Improving the Reporting System

of currently Zoonotic Notifiable

Diseases by 2011

Create a list of the Zoonotic Notifciable Diseases (ZND) by

January 2011

Obtain a weekly report of the ZND by January 2011

Add the Zoonotic Diseases notification form for the ZND by

January 2011

Development of a National

Zoonotic Diseases List by 2011

Accreditation of the list by a committee of experts by March

2011

54


Publicization of the list by June 2011

Brucella Implementation Project

by 2012

Finalization of the proposal by January 2011

Implementation of the project by December 2012

Rabies Implementation Project by

2011

Finalization of the proposal by January 2011

Implementation of the project by September 2011

55



departments, 7 March 2011): 1. All disease surveillance at the FMoH is by the Epidemiology Department and we are working towards integrated surveillance.

No development of new surveillance systems! Any programme that feels the need for a surveillance system should come to us and

we add it to our surveillance, unless they have an eradication target.

2. Any disease that has an eradication program will have its own surveillance till it achieves the target. Meanwhile we should have

exchange of information via joint taskforces to ensure quality and evaluation and to ensure data reports are consistent.

3. Diseases with a control programme. Strengthening the surveillance system in coverage and quality (Assumption: there will come

a point when vertical programmes see surveillance as an extra load and would like us to take this on based on Epidemiology

surveillance coverage and quality). Example: Khartoum State malaria surveillance is undertaken by Epidemiology dept. Outbreak

response is the responsibility of the Epidemiology Department in coordination with programmes E.g. for the yellow fever vaccines,

the cold chain should be the responsibilities of the EPI but the decision is of the Epidemiology Department. However, it is to be

noted that at the workshop, there were also split views with respect to the role of disease control programmes, whether they should

be the lead or the Epidemiology department.

4. Diseases without a control programs; Not discussed at workshop… But propose criteria for inclusion on List A or B to be clarified.

Criteria for review of notifiable disease list. Desk working within Epidemiology dept. and criteria for recommending setting up a

control programme or another existing dept to take over.

5. New/emerging diseases: Preparing case definitions (suspect, probable, confirmed cases) and dissemination of these definitions.

Emergency procedures to include case definition of suspect cases onto list A or B. Procedure to agree when to step down ie take

off the suspect case definition from List A or B

6. Agree thresholds for each disease on the notification list to investigate and control whether single case or calculate mean and

standard deviation (two standard deviations above the mean – too many false alarms, three standard deviations may delay

outbreak) or use statistical process control charts which is highly recommended (threshold of threee standard deviations but also

detects possible outbreaks that are below the threshold).

56


7. Develop a five year roadmap in collaboration with programmes. Monthly liaison meetings between programmes, surveillance

system and health information system to triangulate information on notifiable diseases and new/emerging diseases.

8. Establish routine data sharing from food and water surveillance (routine and not on demand) including the monthly reports from

States. Similarly for vector surveillance. Enhanced surveillance as needed on a geographical basis and for an agreed timescale

when needed for outbreak/incident response.

9. Trained specialised Rapid Response Teams (RRT) should be made available in the states to safeguard against the situation

where, in case of an outbreak, the disease-control-unit‟s own team has to go to the states due to lack of a State specific RRT.

10. Policy issues raised were around the different structures in States versus Federal which makes accountability difficult. Also

other departments need to expand their surveillance for water, food and vector. Legislation to be reviewed to reflect the separation

of South Sudan and regarding compliance with IHR 2005.

11. Define the role of different departments in incident response and undertake structural changes as appropriate to accommodate

new PHEIC requirements

57


Appendix 3: Stakeholder perspectives outside MoH (Report of workshop, 17 March 2011): 1. Decentralisation is the way forward, but it needs to be a phased process and accompanied by central government allocating

resources, authorities and staff to the states.

2. A gap analysis is important based on actual resources, staffing and skills at State level. Particular emphasis is needed for

surveillance as the starting point for early detection at peripheral levels.

3. Zoonotic disease liaison with Ministry of Animal Resources is a good example of coordination, with the establishment of joint

committees, regular meetings, and staff exchanges. However, some zoonotic diseases are notably absent from the surveillance

system like brucellosis and leishmaniasis. This is an important point as most new and emerging diseases are of zoonotic origin.

4. Chemicals and radioactive materials pose a huge risk and hitherto neglected. There are 481 stores for pesticides and many

others of fertilizers beside tons of chemicals used by industry and no one knows how/where. The FMoH should focus on

chemical and radioactive materials.

5. We should have a database. With petroleum industry Sudan is using radioactive sources. (If one lost as happened before in

Egypt it can affect a big population).

6. Forecasting element is important with respect to frequent outbreaks eg meningitis

7. The role of NGOs like Red Crescent is key to community mobilisation. NGOs may have more resources than some SMoH and

should be involved

8. Simulation exercises can enhance preparedness eg Simulation of an airplane crash with Civil aviation authority

9. IHR implementation plan is coupled to this Strategic Plan. The IHR focal point is recommended to be placed within the

Epidemiology Department Director or the Assistant Under-secretary.

10. The media can be used as early warning tool. At the moment, the partnership is seasonal and there is no follow up.

11. Surveillance system should be a one standardized surveillance system with partners (all health providers, e.g. army, health

insurance, police) and all other non-health incidents (radioactive...etc) reporting to it, so the system can detect all the health

threats.

12. Partners are many and they should be many as the concept is larger than diseases. They should be defined with their exact

role, and to be activated so they positively affect the functions. This workshop is to be viewed as the starting point for

stakeholder engagement.

58


13. The epidemiology departments in the states are very important during outbreak but once the outbreak is gone, they are totally

neglected. We should be persistent in being functional during non-outbreak time and run simulation exercise to enhance

preparedness.

Appendix 4: Staff development model suggested by CDC, April 2011

A brief exercise by the department and CDC mission articulated the training needs and numbers to train for staff in Federal, State

and locality departments of Epidemiology. This is depicted as follows.

59


Training modules: It is proposed that staff development be covered through in-country training on three levels

Basic Level (suggested 3mths module)

Intermediate Level (suggested 6-9mths diploma)

60


Advanced level (FETP or Master Equivalent):

Competency framework: A breakdown of competencies at each level is suggested from the following references

FETP (Field Epidemiology Training Programme) competency framework as developed by CDC, and the

IDSR, Africa Technical Guidelines, 2nd Edition, 2010

61


Appendix 5: Participants in MoH Departments workshop (not mentioned in page 5)

1. Nahid Abdulla Abdelrasoul

2. Saidg Mohammed Isamel

3. Hasan Basheer Ahmed

4. Abubaker Osman Elhaj

5. Khalid Elwaleed Faroug

6. Salwa Abdelrahim Sorkati

7. Salaheldin Abdelrazig

8. Mohammed Shayeb

9. Dina Abdelhameed Abdulla

10. Adil Ahmed Ismael

11. Mariam Elhadi Idrees

12. Tarig Abdulla Abdelrahim

13. Lubna Mohammed Yahia

14. Mutaz Ahmed Mutaz

15. Asia Azrag

16. Mubarek Elkarsh

17. Mohammed Osman Maysra

18. Magdi Salih Osman

19. Isra Mirghani Makki

20. Majda Nugudellah Ahmed

21. Anwar Mirghani

22. Amani Abdel Moniem

23. Anoud Rashad Ibrahim

24. Muhtadi Mohammed

25. Yara Baderldin Elshaikh

26. Ahmed Mubarek Ahmed

27. Mashael Mohammed Fadoul

28. Balgees Elkhair

29. Wafa Taha

30. Hafiz Ahmed

31. Shaza Muhieldin

32. Izzaledin Ali

33. Amal Omer Elbashir

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Appendix 6: Participants in external partners workshop (not mentioned page 5)

1. Hashim Elwagee

2. Elfatih Zain Elabideen

3. Eltahir Awad Gasim

4. Ibrahim Hasan Ahmed

5. Suzan Salaheldin

6. Awad Nimir Salih

7. Nouf Osman Ahmed

8. Mohmmed Ali Awadelkreem

9. Haidar Abu Ahmed

10. Entisar Elrayeh

11. Kamil Mirghani

12. Salah Yosif Ammar

13. Khalid Mohammed

14. Eltayeb Ahmed Eltayeb

15. Neelan Bhandy

Documents

2012-2016fmoh.gov.sd/St_Paln/StEpiJune Version.pdf · Dr.Babikir Ahmed Magboul Somia Okoud Dr.Magdy Mahjoub Dr. Mohammed Abdelrahman Dr. Linda Awad Mustafa Dr.Layla Abdullah Dr. Ali