Federal Ministry of Health National Government of Unity/ MDTF

1. Federal Ministry of HealthNational Government of Unity/ MDTF Decentralized Health System Development Project (DHSDP) Final Project Proposal OC Meeting August the 28th, 2006

2. Contents of the presentation • Project preparation process • Context and key health sector development issues • Targeted states and health indicators in the selected states • Project Description • Project Development Objective and Key Performance Indicators • Project Components • Performance indicators • Project Costs • Implementation arrangements • Institutional and Implementation Arrangements • Procurement Arrangements • Financial Management Arrangements • Monitoring and Reporting • Sustainability and Critical Risks • Next steps

3. Project Preparation Process • Initial Project Proposal considered by Health Thematic Group and approved by IOC in February • 2 consultative meeting were convened and provided invaluable inputs to the project development (February and June (health coordination meeting and HTG) • More than 20 core team meetings • State-level planning and consultation • State Ministries of Health consulted on IPP • Field missions to targeted states were completed (all parts of each state) • Project Implementation Plan developed (1 workshop in each state 2 workshops in the federal level) • Detailed technical planning to continue during project implementation

4. Project Preparation Process • As part of project planning and consultation, environmental, social and gender assessment in the four target states has been done: • Assessment missions have highlighted significant social, cultural, financial, and conflict-related barriers to health care facing women and vulnerable groups particularly • An Environmental and Social Management Framework (ESMF) and a Resettlement Policy Framework (RPF) have been chosen as mitigation instruments

5. Key health sector issues Poor PHC infrastructure and performance and low level of access to and utilization of health services • Overall, but specially in the four target states there are large deficiencies in existing public health services • Key staff are deficient, poorly deployed, paid and motivated and often have insufficient technical knowledge and skills • Although early phases of pharmaceutical supply system exists (RDF) the supply of pharmaceuticals to lower levels health facilities is uncertain, • Basic equipment is lacking and working conditions are poor and quality of care is low, • In many areas of the target states, there is a basic lack of health facilities and services, with limited support from non-governmental organizations (NGOs)

6. Key health sector issues Large disparities and deficiencies in health services and outcomes • Averages of MDGs health indicators in Northern Sudan are low, but often better than Sub-Saharan Africa averages; • MMR 509/100,000 • IMR 68/1,000 • U5MR 104/1,000 • Low levels of access to and utilization of health services • However, these averages masks significant urban-rural and regional disparities, related to conflict, displacement, and poverty;

8. Key health sector issues Major financial and social barriers to access to health services • the Social and gender assessment has shown that: • even in situations where a supply of health services exists, there are major barriers to access by women, vulnerable groups and the poor in general • the cost of user fees and medications prevents many poor households from accessing health care, • many social, cultural, and conflict-related issues have an impact on overall health and access to care

9. Key health sector issues Decentralization, fiscal federalism and the financing of health services • responsibilities for health care services are decentralized; • the national level commands the bulk of growing fiscal revenues; • primary and first-referral health care services in the poorer states suffer from under-financing and inequitable allocation of resources. • the Federal Government is increasing fiscal transfers to the state governments; and • committed in its Interim Constitution to emergency and basic health services free to the user.

10. Key health sector issues • Health financing and the MDGs • primary and first-referral health care services in the poorer states suffer from under-financing and inequitable allocation of resources. • the (JAM) estimated that additional resources of approximately US$ 215 million would be required annually in the next two to three years in order to achieve significant progress towards the MDGs over all of Northern Sudan • This project is 19 million US$, targeting 4 states, then leaving a gap of 196 Million US$ annually??? • Bilateral support? • Government investment

11. Project Description Project Development Objective (PDO ) • Consistent with overall health sector vision to move towards achieving the MDGs and improve equity • Improve access to quality basic health services by conflict affected populations in conflict-affected and underserved states (4 targeted states, 5.1 Million) • Improving the capacity of the decentralized health system to establish the basis for wider health sector reforms, sustainable financing and sector development

12. Project Description • Project Components • Component1: Expanding access to primary health care services by underserved populations • Component 2: Development of the decentralized health system and establishing the basis for wider health sector reform, sustainable financing and development

13. Component1: Expanding access to primary health care services by underserved populations • Objective: to improve access to primary health care services and high-impact health interventions by conflict-affected and underserved populations in the target states in the immediate term, • Sub-component 1.1. Expansion of coverage of primary health care services and high-impact interventions. • Key interventions and strategies • injecting new resources into the public system, improving service quality and allowing reductions in user/consultation fees • finance mobile and temporary clinics managed and supplied by the State MoHs using government health workers reallocated from better-served areas • contracting out for some interventions to private providers • provision of high-impact health interventions directly to communities and households,

14. Component1:Expanding access to primary health care services by underserved populations • Sub component 1.2: Pilot experiences to reduce barriers to access to primary health care services • Key interventions and strategies: • Evaluate the implementation, effect on service utilization, and financial feasibility of subsidies for primary health care services with high impact on morbidity and mortality • Measure the cost and impact on service utilization of financing the health insurance premiums for all children under-five and pregnant women in an area where the State Health Insurance Fund is functioning • Assess the effect on health service utilization by women of interventions designed to address gender-related barriers to access • Other pilot experiences will be implemented as needs and opportunities for learning are identified during project implementation

15. Component 2: Development of the decentralized health system and establishing the basis for health sector reform Objective:Increase the capacity of the decentralized health system to establish the basis for sustainable financing, reform and development.

16. Component 2: Development of the decentralized health system and establishing the basis for health sector reform Sub-component 2.1 Capacity building and policy for the development of the decentralized health system • Key interventions and strategies • Health care financing (NHA, TA, policy and strategy development • Pharmaceutical supply (TA, studies) • Health planning, budgeting and management by target State and Locality health administrations • Improving the HMIS and Monitoring and evaluation systems, and other systems (capacity of administrators effectively analyze and use data )

17. Component 2:Development of the decentralized health system and establishing the basis for health sector reform Sub-components 2.2. human resources for health development (improvements in the production, quality, deployment and retaining of the PHC workforce. ) • Key interventions and strategies: • Development and endorsement of health sector-wide HRH strategies, policies, and practices • State PHC human resource development strategies • Curriculum review and teacher in-service training. • Rationalization and investment in training schools and equipment (Health Science Academy)

18. Component 2:Development of the decentralized health system and establishing the basis for health sector reform Sub-component 2.3. Investment in primary health care infrastructure and equipment • Key interventions and strategies: • The aim is to make the provision of the basic package of health services possible • Upgrade and expand the PHC infrastructure focusing on the areas where the network of health facilities is weakest • Improve the quality of services delivered aiming at improving access and utilization • Investment in PHC infrastructure and equipment will be closely coordinated with project’s immediate support to service delivery under sub-component 1.1.

19. Component 2:Development of the decentralized health system and establishing the basis for health sector reform Sub-component 2.4. Project implementation • Personnel and resources necessary to manage the project and coordinate the project activities at the federal and state levels • Aims at building needed capacities and supporting the existing institutional structure

21. Performance indicators

22. Project cost and proposed Budget

23. Proposed Budget

24. Allocation of budget between states • Budget allocations to support activities in the four states were determined on a simple per capita basis for Phase1 • Overall increase in public per capita investment 3.33 U$ • Simulations of allocation formulas which include population, federal per capita fiscal transfers to the states, and population per health center, provide results not significantly different from simple per capita allocation • Allocation within the states will target impoverished and underserved areas (equity)

25. Proposed Budget

26. Annual Planning & Consultation • To assess progress, adjust planning, reallocated budget • Broad-based consultation in each state • Built-into project implementation and M&E

27. Implementation arrangements • State consultations and planning • Planning and consultation processes have been carried out during project preparation at the state level, involving all major stakeholders • On the basis of this process, a Project Implementation Plan (PIP) was developed and agreed

28. Implementation arrangements • Institutional and Implementation Arrangements • The FMoH will be the executing agency, working in close cooperation with partners and the SMoH of the four target states • A Federal Project Implementation Unit (FPIU), established in the FMoH will have overall management and coordination responsibilities • Within the target States, a State PIU (SPIU) will be established within the SMoH for the day-to-day management of project activities • Federal and State Steering Committees: with representation from the Federal and State Ministries of Health and Finance, as well as other partners (WHO and UNICEF, etc…) will be established and provide overall strategic orientation and oversight for the project

29. Proposed Implementation Arrangements

30. Procurement Arrangements • The procurement capacity of the Federal and State Ministries of Health is weak in terms of technical personnel and application of procurement procedures • The project will recruit qualified Procurement Specialists to carry out procurement functions and build the capacity of the MOH • In order to enhance early start up of project activities after effectiveness, the Federal PIU will be established as soon as possible so that it can embark on procurement activities identified and listed on the Procurement

31. Financial Management Arrangements • PIU will recruit a financial management officer who will be responsible for: • putting in place a computerized accounting system; • establishment of appropriate procedures for recording all project expenditures and commitments; • timely submission of requests of replenishment of funds from MDTF and the Government contributions; and • periodic reporting of project expenditures

33. Monitoring and Reporting • A strong monitoring and evaluation (M&E) function is critical to this project, • The Federal PIU will be responsible for overall M&E and reporting on the project, in close collaboration with the FMoH Planning Directorate and Health Management Information System (HMIS) • Each State PIU is responsible for M&E and reporting on project activities and performance in the states, • Contracting technical assistance to the Planning Directorates and HMIS of the Federal and State MoH to support project M&E. • Capacity building in health information management will be a critical component of this technical assistance.

34. Next steps • Project Effectiveness planned for September • Requires: • That consensus on priority activities have been determined for the target states, meeting the objectives of the project, particularly in improving access for conflict-affected and underserved populations • That project implementation capacity has been put in place (technical, financial management, procurement)

35. Thank you