Report of a WHO/UNHCR Evaluation Mission to Eastern Sudan

18-28 June 1998
prepared by:
Dr Khalid Shibib, World Health Organization (WHO)
Dr Mohammed Dualeh, United Nations High Commissioner for Refugees(UNHCR)


The Sudan refugee programme established in 1967 is UNHCR's longest running programme in Africa. About 134,639 refugees live in 18 settlements located in 4 States in Eastern Sudan of which 89% are Eriterians, and the rest are Ethiopians. The repatriation of Ethiopians which is currently ongoing is expected to be concluded by end of May 1998, followed by the status determination of the residual case load.

About 49% of the refugee caseload are males and the rest are females. According to the disease surveillance reports about 17% of the refugees in the camps are children under 5 years of age.

Repatriation is the main priority for the durable solution of the refugees in the Sudan. Repatriation of the Eriterians is expected to commence in 1998 pending a breakthrough in the current ongoing negotiation between UNHCR and government of Eritrea.

Many refugee camps have a population of less than 5000. There are only 843 individuals in Wad Awad. Basically same clinics should be run for all settlements which is influenced little by the camp population. Therefore, Branch Office Khartoum is pursuing camp consolidation and closure with the government to reduce overhead cost and rationalise limited resources. Although significant progress was made in the negotiations, camp consolidation/closure did not start yet.

UNHCR has Sub-Offices in Showak and in Port Sudan while COR has offices in Showak, Gedaref, Kassala, Wad Madani, Port Sudan and in all settlements. Most of the camp are located far from Showak often requiring long distances of travel in roads which become impassable during rainy season from July to September each year.

In the Red Sea State UNHCR provides social services such as health and sanitation to about 3,000 refugees in Asotirba camp near Port Sudan. WFP does not provide general ration to the population in the camp who are mostly employed in transport or have business in Port Sudan. Sudanaid, a local NGO, who was providing health services in the camp has withdrawn from Asotirba in March 1998. Since the case load in the camp is small and since it is believed that the refugees in Asotirba are relatively much better off than other camp based refugees, UNHCR Sudan is negotiating with State Ministry of Health to take over the health and nutrition services in the camp and integrate that with the national health services. Asotirba could be viewed as pilot exercise the outcome of which could be replicated in other States.

With the assistance of UNHCR, COR Health Unit co-ordinates all health, nutrition and sanitation activities in the refugee programme. The unit which is located in Showak has nutrition, MCH, health education, statistics, sanitation and pharmacy sections. The function of the unit is to supervise and provide support to medical teams in the camps. It is headed by a physician seconded from the Ministry of Health, and is responsible to COR and to Federal Ministry of Health. The Unit is vested with the responsibility for ensuring that refugee health programmes are implemented in accordance with MOH policies and procedures.

All the health activities in the camps are implemented by 5 local NGOs who replaced International NGOs in the last several years. Christian Outreach and Lalamba were the last two International NGOs which phased out from the refugee programme in 1996 and 1997 respectively (see Annexes).

Over the many years since when the refugee programme was established, International NGOs has provided health and nutrition services in the camps, while the activities of the medical teams were all based on primary health care, the procedures and strategies of implementation have varied among the NGOs, some times significantly so, due to different inclinations and priorities. Some of the NGOs have encouraged full community participation while others did so at a much less scale. Some of the health programmes were markedly curative oriented with little emphasis on prevention. Each NGO had its own medical referral system and procured medicines and medical equipment on its own. Due to these differences, activities in the camps, from medical referral to basic record keeping, have required intensive review and standardisation after phasing out of International NGOs from the camps.

The refugee sanitation activities in the refugee camps were modelled according to the set up of sanitation programme in urban towns in Sudan. The latter is labour intensive and has little or no community participation. This unnecessary linkage has lead the refugee programme to hire workers for the waste disposal in the camps instead of involving the community. On the other hand, the vector control operation in the refugee camps has been developed over time in manner which is significantly detached from the practices of the national vector control programme. This has resulted the continuos procurement of various types of insecticides for the refugee programme without this being done in the national programme. The sanitation activities in the camps were streamlined in the last 2 years to address the above discrepancies.

Over the years, NGO medical teams have trained refugees to work in the health and nutrition activities as Community Health Workers as well as nurses, Assistant Pharmacist and laboratory technicians. However, many of these refugee workers, particularly mid-level health workers, have left the camps in the past 5 years for various reason. Currently, most of the health workers in the camps are either newly trained refugees or are Sudanese.

According to nutrition surveys conducted in the camps in 1997, the nutrition status of the refugees varies among the camps, the condition being worse in the camps with higher population figures. This nutritional disparity might reflect difficulty due to an increased competition of refugees in the large camps to outside resources compared to those in small camps.

SCF-UK has conducted food security assessment prior to WFP/UNHCR joint food assessment mission in 1997. The mission concluded that the food situation of the refugees in labour camps is precarious due to intensive competition of the labour market by younger Sudanese workers. The mission's finding has led to an increases of the ration given to some camps and continuation of the same food basket for the others.

Following the visit of the Senior Reproductive Health Officer to Sudan, efforts in the programme towards meeting basic health needs of refugee women were increased. Services of Family planning, sexually transmitted diseases and safe motherhood were reviewed. These activities were strengthened through training of health workers and developing procedures and guidelines for implementation. A UNV physician with MCH experience was recruited by UNHCR at the end of 1997 to co-ordinate RH activities. However, all of the above initiatives in this sector did not achieve their intended goals mainly due to lack of adequate follow up in the field.


There are three motives for UNHCR to carry out this review mission:

1. The last programme review was three years ago. Since that time, the national health policy and the national health system have substantially changed. The last national workshop on refugee questions was in 1989.

2. Increasing awareness that over decades, the linkage UNHCR/COR has taken an exclusive character, which is perceived as having some technical, political and financial drawbacks

3. The recent fluctuation of the staffing has weakened the health unit of COR, and therefore the system in general.


The mission team has carried out the following strategy to evaluate the refugee health system

1. Field visits to the refugee camps (four refugee camps health services were visited). This was always combined with a visit to the national health services in the area nearest to the camp

2. Interviews: Dozens of health providers within the camps, within the State and Federal Ministry of Health, within the structure of COR and NGOs were interviewed. The interview were sometimes structured and were focussed on the health status, health care delivery system, information (recording and reporting channels) problems and bottle necks, scenarios and relation between the refugees and national health systems. The mission team has met with the Director General of the MOH in Kassala and in Gedaref States, with H.E. the MOH in Gadaref and with H.E. The Wali of Gedaref as well. In addition, the mission met with Dr Zaidan, the Director of International Health at the Federal Ministry of health in Khartoum, who send a member of his ministry to join the mission team throughout the mission.

3. Compilation of secondary data and reports: for the health status of refugees, the reports issued by COR were the main source of information. The report of the WFP/UNHCR assessment mission and that of SCF/UK last February. Organogrames and TOR of the various structures dealing with refugee health were only partially available

4. The conclusions and the findings were then presented to the concerned parties (UNHCR,COR,WHO and FMOH) at the Showak and Khartoum levels. The recommendations were discussed and adjusted with these actors.


  • On the eve of the mission, there were rumours that the evaluation exercise will be a budget cutting one. This has led to misunderstandings, personal tension and resistance to the activities of the mission. Repeated assurances that the UNHCR is not intending to cut jobs and that this is a routine evaluation exercise has lead to calming down of various parties towards the end of the mission
  • There were also misperceptions concerning integration. Many COR staff came from the MOH and keep good personal relations with their previous colleagues. It was widely thought that integration was meant to handover the health services to the Ministry of Health and phasing out by UNHCR.
  • The mission was not able to carry out all the activities needed within the time frame of the mission. In the field, the team was based in Showak and has to travel every day to places that are far a way from Showak. The work in Sudan (including in the refugee health programme) begins at 8:00 and finishes at 2:30 p.m. Some centres visited after this time schedule were empty.
  • The mission team didn't go to the details of technical programmes, but focussed its evaluation on the following fields

Policy issues


Information management

- quality of records and reports

- information processing (collection, storage, analysis and interpretation, presentation and dissemination);

Commanding structures: lines of reporting/authority and supervision

Inter-system relations: relationship between the health care delivery units and between them and their HQ. Special emphasis was given to explore relations between the refugee health system on one side and state and national health system on the other side.

  • The biggest refugee camp visited was Wadi Sharifi in Kassala State. The camp is located about 3 km from the Eriterian borders and was subjected to shelling in the last three weeks. The mission was able to visit some of the victims of shelling in the SRC clinic in the camp. There was no shelling in the two days spent by the mission in Kassala and Wadi Sharifi.
  • The refugee health system is based on the primary health care concept (mainly preventive) while the governmental health care delivery system is centred around the hospitals.
  • The introduction of cost recovery and health insurance in the national and state levels has lead to dramatic reduction in the attendance of the governmental clinics. In the areas surrounding the camps, local population burden the refugee health programme (17-22% of all clinic attendance are none refugees)
  • On the other side, It is perceived that the refugees are burdening the national and state hospital services. It was impossible for the mission to backup this perception by hard data, since the recording of both the refugee and state health system is extremely poor. In the hospital records, there are no item for nationality.! In the refugee clinics, reference to hospitals takes place without referral forms and is not separately documented.
  • In Kassala State, where most Eriterian Refugees are living, many Sudanese belong to the same clans as those of the Eriterian Refugees. This is definitely not the case for Ethiopian refugees in Gedaref. Most of the Ethiopian refugees were Christians, while most of the Eriterian refugees were Moslems.
  • A major problem for the national and state authorities are the "Unregistered refugees" and migrants. The Wali of Gedaref for example has sated that in the last few days, unknown number of Eriterian refugees infiltrated the eastern region and they are seen everywhere. In Kassala hospital, the refugees are perceived as a health risk, especially for STD/HIV. This could not be substantiated with data.
  • Although there is a consensus between health providers of both refugee and national systems on the priority health problems (malaria, ARI and diarrhea), there are areas where the sequence was reversed (ARI, diarrhea and malaria were respectively listed to prevail among the Ethiopian refugees in Gedaref State). Leishmaniasis was presented by the local community leaders in this are as a major health problem.
  • COR's Reports on the health and nutrition of the refugees are morbidity and mortality reports. Although the main emphasis and activity of the refugee health system is preventive (health education, immunization, nutrition, environmental sanitation, housing and water), the reports reflect the "curative" side only. The MCH programme for example has no place in the present reporting system. In all reports on the health and nutritional status issued by COR, there was no nutritional data, although some food security data were mentioned. The health data simply put the three common diseases mentioned and list all the remaining cases of morbidity and mortality under "other diseases" without giving details on them. It was impossible for example, to find out if the main budget and manpower resources are directed towards controlling these three most common causes of diseases and of deaths.
  • The mission has chosen to use the term "Refugee Health System" when talking about the hypothetical construct which encompasses the elements (laws, processes and structures) and components (the outputs, the inputs, the constraints and the processor) put together to undertake actions which is in this case to deliver health services to the refugees. In this system, many actors (COR, UHNCR , NGOs, MOH etc. ) act and interact. Although processing of inputs into outputs takes place at any sites within the system, the control unit of the processor is definitely the health unit of COR.
  • The use of "refugee health system" when discussing the findings of the mission had the advantage of de-sensitizing various actors. When the findings (mainly negatives) were elaborated, no party has the perception of being targeted, while when the recommendations were made, specific actors were always involved.
  • The health budget of UNHCR is around 25% of the total refugee programme budget. This way, it is the largest single non-food programme as such.


Conclusion 1

The refugee health programme is vital for the health and wellbeing of the refugees in Eastern Sudan


1. The refugee community is unable to carry the load of establishing and sustaining its own health system without external assistance

2. The National and local health system cannot deal with the burden of the refugees;

3. Preventive and curative services are provided to all refugees in their locations


The Refugee health programme should be maintained

Conclusion 2

1. The refugee health system is weak

2. The peripheral health services substantially vary in quality

3. The technical backup of the system is week. No processing of scientific knowledge by the health unit

4. The supervision of health activities in the camps is sometimes non-existing Supervisory visits of the Health Units to the field were very few where visits took place they were too far apart to be meaningful (The breakdown of health services of Um/Rakuba in 1997, without the knowledge of the Health Unit, is a good example.

5. The management of essential drugs and other medical supplies is not properly carried out

6. The recording and reporting of raftered refugees to the national health care delivery system was difficult to trace


1. Efforts should be intensified to engage reputable NGOs with the implementation at the camp level

2. The health unit at COR should be technically strengthened and empowered

  • a.The logistics for the health unit within COR needs to be strengthened
  • b. Adequate manning of the technical subunits (nutr, EPI, MCH,etc) with competent and qualified staff
  • c. UNHCR should reconsider the discontinuation of the post of health coordinator, in support of the health unit.
  • d. Channels and procedures for wider technical cooperation with technical health institutes like the MOH and its collaborators ( WHO, UNICEF and UNFPA) should be established.

3. Structured plan of supervision by the technical subunits in the COR health unit should be formulated, and implemented. This should also be reflected in the monthly reports. The technical subunits must have the capacity to analyse information and to properly respond whenever necessary

4. The central pharmacy in Showak should be properly manned. In addition, a pharmacy system that extend from the centre to the camps should be established (training, procedure and necessary equipment).The pharmacy subunit should provide reports which enables the linkage between drug consumption and morbidity patterns.

5. The recording and reporting formats should be revised and improved. The quality of information at the peripheral level should be regularly controlled

Conclusion 3:

The refugee Health System is almost totally isolated from the National health system


The annual plans of the refugee health programme are formulated by COR and UNHCR without involvement of the MOH;

Certain sites of the State Ministry of Health (usually the Director General of the SMOH) receive reports on " Health and nutrition status of refugees" in unknown regularity

The Peripheral national health services are unaware of the refugee health system

The Federal MOH receives almost no reports from the Refugee Health Programme

The records of the RHS are not identical with those of NHS

The reporting system of the refugee health programme is extremely vertical and centralized as follows:

Refugee camps reports to COR/UNHCR in Showak which reports to Khartoum. From Khartoum, UNHCR inform UNHCR Geneva who contact technical WHO divisions. Thereafter, support is searched from WHO and /or its collaborating centres all over the world (if necessary) . In all this route, there is no instituted procedure to inform the local and State Ministry of Health. In extreme cases, Showak, Khartoum, Geneva (and beyond) could be more and earlier informed on disease problems in Wadi Sharifi Camp that the State Ministry of Health in Kassala which get the monthly report as usual (if there is one). In reality, the strong personal realtions between MOH and COR satff, which is part of the Sudanese culture, may have prevented such odd scenarios.!!


1. Closer linkage between the Refugee health system with its various levels (Khartoum, Showak and camps) with the corresponding structures of the MOH (Federal Ministry, State MOH and local health authorities). Co-ordination and integration should be carried out at different levels.

Policy Formulation Level:
A common health policy must be defined. The health of refugees should be in line with the national health policy. For example health economy, cost sharing, revolving funds, primary health care strategy etc. should be mandated to work together so the national health policy adopted by MOH will be in harmony with the health policy adopted by COR. There should be strategy co-ordination between MOH and COR at the following levels.

Strategic Planning Level:
The planning of refugee programmes should be carried out by joint planning committees. Dates should be established and planning cycles formulated. There should be collaboration between MOH and COR and the approach known to both.

Operational Level:
This should follow MOH guidelines. Ensure flowing of information (based upon selected health indicators) from the operation level to the district, state and federal levels and feedback. On the spot and feedback corrective measures are mandatory.

In addition the local capacity at all levels should be built up through the establishment of appropriate units and bodies at the different levels and the training of health care workers.

Refugees not in settlements:
Methods should be established to determine the degree and magnitude of the health problems of refugees not in settlements and their level of impact upon the resources of the health system.

Precisely, this includes the following recommendations:

  • a. engaging MOH during the annual UNHCR/COR planning exercise
  • b. extending the information on the refugee health to both local authorities and the Federal Ministry of Health;
  • c. Both COR and the MOH to plan and carry out the mutual utilization of available resources for training purposes, as long as this does not interfere with one's own programme activities.
  • d. ensure persistent participation of the State Ministry of Health in the monthly Volag meeting;
  • e. Regional (State) Volag meetings can be organized, also with participation of SMOH;
  • f. participation of COR in the planning process of both the federal MOH and the State MOH;

2. UNHCR/COr should consider the issue of Newsletter on refugee issues in Sudan on regular bases (Quarterly for example), with a health component. The Annual COR or UNHCR reports could also be extracted for this purpose.

3. Refugee issues should be given information space in the mass media in its entirety and , not only as a burden

Conclusion 4:

The refugee health system is rigid and irresponsive to global and national changes


1. While the government has introduced the cost recovery system, the refugee health system remained unchanged. The question of impact of this change in the policy was not even studied.

2. The decentralization of the national health care delivery system has not triggered a process of change within the refuge health system

3. The decline UNHCR resources, as a funding agency-has not yet stimulated any brainstorming or discussion within the refugee health system. This decline of resources has not yet affected the refugee health programme, with the exception of the general staff cuts

4. In the prospect of eventual repatriation of refugees, the assets of the refugee health system should be geared towards the long term developmental goals of the government. This scenario was never discussed within the RHS at any time.

5. In the prospect of further influx of refugees from neighbouring countries to the eastern regions, it is expected that the living conditions of old refugees and local population will be affected. Although there are discussions within COR and within UNHCR, nevertheless, these are taking place separately and are not linked to the contingency plan of the State or the country.

6. The Changes within COR in non-health sectors

  • a. The classification of refugees for food entitlements, the cost recovery the water provision system has not changed the RHS's policy of universal services for everybody in the refugee health system.
  • b. While the assistance provided in the food sector is measured both in calories and in grammes off food items, and in the water sector by the number of litres of potable water per capita, no effort has been undertaken to quantify the entitlement of the refugees in the health sector.
  • c. There is a uniform application, in terms of the numbers and categories of staffing, among camps with different population estimates.


1. The refugee health system should very carefully begin the discussion on the question of introduction of the cost recovery system in some services for some categories of refugees as applied to food and water. The resources coming from this exercise should be programmed for further improvement of the refugee and national health system

2. A national workshop on refugee health can be organized (like that of 1989) to discuss plans, constraints, potentials and future perspectives.

3. The subject of a COR/UNHCR library on refugee issues should be explored. The international social sciences are rich with literature on refugees which could obtained from INTERNET and are available in CD-ROM or hard copy forms.

4. Relations between COR and educational institutions in the country can benefit both sides. For the medical faculties in Sudan, a unique chance of studying, practising and promotion of the primary health care concept is available in the refugee camps in Eastern Sudan. For COR staff, this open the road for Diploma oriented studies in refugee health.

5. Establishing a relation /Twinning between COR and reputable Refugee study institutions should be explored. Examples are the Norwegian Refugee Council and the Brookings Institution -Refugee Policy Group , and others


18.06.1998: arrival in Khartoum via Frankfurt

19.06.1998: Meeting with Dr Mohammed Hassan Qassim, UNHCR Health Co-ordinator in Khartoum.

20.06.1998: Briefing session with UNHCR:

Briefing at the MOH...

21.06.1998: travel to Showak/Eastern Region

22.06.1998:Travel to Kassala and visit to Khashm El Girba Health centre. Return to Showak

23.06.1998:Travel to the refugee camp Wadi Sherifi and return to Showak

24.06.1998:Travel to Gedaref State, meeting MOH and the Wali. Visit to Tawawa Camp and return to Showak

25.06.1998:Travel to Umrakuba Camp in Gedaref

26.06.1998:Travel to Khartoum

27.06.1998:Debriefing in Khartoum

28.06.1998:Travel to Geneva


H.E. The State Minister for Refugees

Commissioner of Refugees, Dr Mohammed ElSheikh AbdelAal

H.E. The Wali of Gedaref,


Ms Mervat Mohamed, resposible for NGOs/COR

Mr AbdelRahman Ali, Training/COR

Dr Khalafallah El Awad, health unit/COR

El Bakir Naser, Senior public Health Officer

Dr Amina.. responsible for training

Mr Ahmed Ibrahim Al Faki, acting Deputy Commissioner/COR- Showak

DR Taj El Sir Mohammed Kheiry, Director General of the SMOH- Kassala

Mr Elthir Emam, COR Showak,

Dr Badr El-Din Baddour, Sudan Red Crescent (SRC)-Kassala


Dr Zaidan, Director of International Health/Federal Ministry of Health,

Dr Hatem, Department of International Health/Federal Ministry of Health,



The Director General of the SMOH, GEdaref

The Director General of the SMOH, Kassala

Kassala State Hospital

Dr Mohammad Zain El-Abdeen:ENT specialist/Kassala State Hospital

Dr Mahmoud Ali Adam Pediatrics and Gynaecology/KSH

Dr Taha Abdel Fattah, Psychiatric Department/KSH

Dr Bakri Abdelkarder Ouais/KSH

Dr Afaf Mohamed Ahmed/KSH

Mr A AbdelKader Maher Admouz, Director, governmental clinic-Wadi Sherifi village

Mr Ibrahim Elhaj Mahmoud Medical Assistant, Wadi-Sherifi governmental clinic ..

Besides, the team met with community leaders of both the Eriterians and Ethiopian refugees in their camps


Mr Peter Okoye, Acting Representative

Mr John Adu, Senior programme officer, UNHCR

Dr Abdullah Ismail, WR-Office in Khartoum

DR Mohamed Kassem, Medical Coordinator, UNHCR- Khartoum,

Mr El Taib Hussam, UNHCR Showak,



Specif. site
Origin of refugees
RH status
Budget (US$)
Wadi Sherifi
Shagarab,Girba, Karkora
Abuda, Umali
Aburakham area, Mafza, Hawata
WadHileua, Fau5


COR: Commissioner for Refugees *Budget is total for all Health services
IARA: Islamic African Relief Agency *In addition, an estimated $600,000,outside of the
SRC: Sudan Red Crescent above budget, are spent on drug purchase or
HAI: Human Appeal International are donation from other UN agencies to the
BIO: Benevolence International Organization health programme.
SCC; Sudan Council Of Churches


UNHCR-Health Coordinator Annual report for 1997



Following 1996 census, the official number of the refugees in the camps has dropped from 300,000 to less than half of this figure. Ongoing repatriation has further reduced the case load. At end of 1997, 134,639 refugees were in 18 settlements located in 4 States in the East of the country. About 89% of these are Eritreans while the rest are from Ethiopia. 17% of the population are children under 5 years of age. Male to female ratio in the camps is 1:1. About 43% of the refugee population live in 2 (Wadi Sharifi and Shagarab) out of the eighteen camps. 12 settlements have populations less than 5000.

Based on their location, refugee camps are divided into "wage earning" and "land based". The former are located near urban centres or agricultural schemes where refugees could seek casual work. In the land based camps refugee families have access to plots of land for cultivation. Availability of casual labour around the refugee camps became a tough pursuit recently since an increasing number of young people from South/West of Sudan started seeking work in Eastern Sudan in great numbers in the last several years.

The refugee programme in Sudan is the longest in Africa and since its inception in 1963 a number of factors had an important bearing on the direction of its development, particularly in the health services.

  • The Commissioner for Refugees (COR) was vested with the responsibility of co-ordinating refugee health services on behalf of Ministry of Health. MOH has never had a direct involvement of the health programme. This intermediary role of COR has impeded the integration of the refugee and the national health systems in terms of planning, implementation and evaluation of the services. Therefore, while a strong primary health care system was developed in the refugee camps, the main thrust of the national health services remained curative and hospital based. As a result, development of a primary health infrastructure by the national health system in the vicinity of the refugee camps is meagre.
  • The majority of the refugees are Eritreans who share much cultural similarity with the local Sudanese population. In some areas, same ethnic group extend on both sides of the border. Therefore, while the refugees have unimpeded access to casual work in agricultural projects and in the urban towns, a significant number of the local people in the vicinity of the camps benefit from the refugee social services. Accordingly to the outpatient records, an average of about 25% of outpatient consultation in the camps are from the local population.
  • MOH has introduced fee-for-services in the national health system from 1992, but the refugee health programme continues providing free health services in the camps, thus attracting many local people some times from distant locations.


The health and nutrition activities in the camps are implemented by 8 local NGOs namely Human Appeal International (HAI), Sudanese Red Crescent (SRC), Sudan Council of Churches (SCC) Islamic African Relief Agency (IARA), Benevolence International Organisation (BIO), Global Health Foundation (GFO), Al-Rahma Organisation and Sudanaid. Sudanaid is in the Red Seas State. Most of these organisations took over the programme from international NGOs which had phased out from the camps in the last several years. Christian Outreach and Lalamba has phased out from the refugee camps in 1996 and 1997 respectively. The withdrawal of international NGOs from the programme has left behind technical and management vacuum in the health system which required standardisation of the procedures and services and building of the managerial capacity of the NGOs. Names of the NGOs and the sites they work are attached in annex 2. A reduction of the number of the NGO in the health programme is expected to take place in early 1998. COR implements sanitation activities in all the settlements.

Each major camp or a group of small camps is supervised by a medical doctor. Medical Assistants, Nurses and midwives supervise the activities of Auxiliary Health Workers who provide various services in the clinics and carry out outreach work in the sections. While the majority of the health workers in the camps were refugees all along the duration of the programme, many of them had left Sudan in the past several years for various reasons including repatriation and were subsequently replaced by Sudanese health professionals.

In order to update the skills of the health workers in the case management of common diseases, improve implementation of various health interventions and raise preparedness of medical teams for seasonal epidemics, refresher courses are provided to health workers in the camps each year. In 1997 the following workshops were conducted:

1. Midwives workshop 2 day workshop for 18 participants
2. TBAs training course for 2 months for 27 participants
3. Family planning workshop for five days for 15 participants
4. EPI workshop for 1 day for 29 participants
5. STD workshop for 1 day for 20 participants
6. Tuberculosis training for 5 days for 22 participants
7. Nutrition workshop for 1 day for 20 participants
8. CDD workshop for home visitor supervisors

The training focuses on technical and operational challenges facing the programme. In each session the trainers are required to come up with a plan of action based on the recommendations of the participants in a specific subject. However, the follow up action on the recommendations made in the training in 1997 were not carried out as planned due to high turn over of COR Medical Co-ordinators and lack of enough field visits by COR Health Unit. Therefore, the appropriateness or the effectiveness of the training were not fully documented.

UNHCR fully funds health and nutrition activities in the camps including staffing, operational expenses and termination benefits of those who are lied out from the programme for various reasons. The overall budget which was spent on health, nutrition and sanitation sectors in 1997 was about $1.5 million which corresponds to over $10.5/person/year, considering only the population in the camps. However, if the local Sudanese who also use the health services are taken into account, the rate would come down to between $7 and 8/person/year.

With the technical support of UNHCR, COR co-ordinates the health services on behalf of Ministry of Health and is vested with the responsibility of ensuring that MOH policies are followed in the refugee programme. COR Health Units, with its various sections (MCH, Nutrition, Health Education, Pharmacy, Health information System and Sanitation) provides support to NGO medical teams in the camps and supervises implementation of the health activities in the field. Monthly co-ordination meetings are held in Showak for medical teams in order to discuss operational challenges facing the programme and share information on current issues. Monthly surveillance on mortality, morbidity and nutrition is also discussed. Another co-ordination meeting is held periodically in Khartoum for the heads of NGOs mainly to solicit support to the field medical teams.

Since the camps are spread over a wide area and they are often located far from the main public hospitals, transport is vital to the operation of the health services in the camps. However, vehicle maintenance in COR workshop continued to be a major obstacle to the programme implementation in 1997 as in 1996. One of the main reasons which led to measles outbreak among the children in Um/Rakuba camp after 7 months of absence of immunisation was lack of transport for the camps. Vehicles stayed in the workshop for prolonged periods, some times for months, only to come out in a worse condition than before.

Suggestions for UNHCR to give vehicle maintenance funds directly to NGO medical teams appears to be the only solution to this chronic problem but this move have not been yet implemented by the office.

3. Health status of the refugee population

3.1 Health indicators

Sudan 1997/8
Refugees 96
Refugees 97
Crude Birth Rate
Crude Mort Rate
Under5 Mort Rate
Infant Mort Rate
1000 live Birth
Low Birth weight
Percent of births
Maternal mortality Ratio
100,000 live births
Annual growth rate %

The above health indicators suggest generally that the mortality in the refugee camps is lower than in the local population. The data also indicate that the mortality in the refugee camps was slightly lower in 1997 than in 1996, although a more closer look in the breakdown of mortality by camp suggest that the drop is perhaps due to incomplete reporting from some of the camps.

3.2 Surveillance

Morbidity and mortality tables and graphs from 1996 and 1997 disease surveillance are presented in annex1. Graph 1 shows the trend of crude mortality rates for the two years is slightly lower in 1997 than in 1996, although the pattern of the trends in the two years are very similar. Mortality have peaked both years from April to September, probably echoing the seasonal diarrhoea and malaria epidemics.

A break down of the total mortality for "all age" group by camp is much more revealing; the peak of Um/Rakuba camp stands out from the rest of the other camps in 1997 while Shagarab, Tawawa and to some extent Um/Gulja have shown less but still prominent peaks. It is important to note that the mortality rate in Um/Rakuba was higher than the average in both years, underlining the importance of giving special attention to the camp in 1998.

Cause-specific trends of the three major diseases namely malaria, diarrhoea and respiratory tract infections are presented in Graphs 3,4,5 respectively. The malaria peak which is observed in April 1997 could be due to other causes of fever and needs to be further verified. Possibility of similar increase of mortality in 1998 should be watched out closely. However, up ward trends in graph 3 in the later part of both years coincide with the expected rise of malaria transmission during the rainy season. Residual spraying was used in the refugee programme for many years to control malaria transmission during the rainy season. However, the benefit of this measure as vector control in the refugee programme have not been supported by a scientific evidence so far. Therefore, insecticide spraying in the programme is currently under a review.

The rise of diarrhoea deaths from April to July in both years (graph 4) reflects seasonal diarrhoea epidemic in the under5 children which occurs yearly in the camps and in the surrounding locations. The peak underlines the importance of medical NGOs to double their efforts against diarrhoea in the camps at this time in each year. It has been found repeatedly in studies that preventive/promotional measures coupled with good case finding and case management could greatly minimise diarrhoea deaths in developing countries.

Mortality trend due to respiratory tract infection which is presented in Graph 5 does not indicate any specific pattern of the disease in the two years. The monthly rates in the graphs indicate the importance of acute respiratory infections (ARI) as a third cause of death in the camps.

Total under5 mortality for the two years which is presented in graph 6 shows that there was a lower trend of mortality and a shift of the seasonal peak to the right in 1997 compared to 1996. The lower trend in 1997 could be explained by the lower rates of diarrhoea and ARI of the same year (graphs 7,8 respectively). An interesting observation, however, is the shift of the peak of diarrhoea deaths to the right in 1997 and its overlap with malaria seasonal peak. Here, the likelihood of misclassifying malaria deaths as diarrhoea should be ruled as malaria could manifest itself as diarrhoea. The two diseases could be difficult to differentiate clinically in a primary health care setting, particularly when under 5 years children are concerned. Accordingly, it is strongly recommended that all medical teams should review malaria case management in the camps in 1998 with a particular emphasis in under5 children. Suspicious children with diarrhoea should have a malaria smear taken.

Camp specific under5 mortality in graph 7 singles out Um/Rakuba and Shagarab camps as having higher rates than the average in 1997. Shagarab had also the highest under5 mortality rate in 1996. However, concerted efforts in 1997 has apparently improved the situation, although it is obvious that it is necessary to maintain the focus on this camp in 1998. Um/Rakuba has the highest under5 mortality of all camps in 1997.

Proportional causes of mortality for "all ages" and for under5 children in 1997 are shown in graphs 11 and 12 respectively which indicate that malaria, diarrhoea and respiratory, in this order, were the most important causes of mortality. The same pattern was repeated in the previous years.

The overall morbidity rate reported from the refugee camps in 1997 (also in previous years) is higher than expected. Morbidity rate reported from Suki camps indicates 8 visits per refugee/year compared to 4 visits per refugee per year during emergency situation. Considering stability of the Sudan programme, the reported rates are high. Clinic consultations for the refugee and for the local population are usually recorded separately in the camps. Therefore, it is unlikely that the high rates of the refugee camps could be contributed by the local population. However, if the consultations are ineffective in the camps, these could lead to repeated clinic visits for the same condition and might explain at least partially the high rates. Therefore, it is important that both the quality of the consultations and the way the data is collected and reported in the camps are reviewed. Use of treatment protocols and adoption of case definitions for common diseases in the camps should be reviewed in conjunction with prescribing practices.

Malaria and diarrhoea-specific morbidity trends in graphs 17 and 18 repeats the pattern seen earlier in mortality and will not be discussed here any further. The proportional causes of morbidity for "all age" and "under5" groups shows a picture similar to that of mortality.

4. Specific services

4.1 Safe motherhood

In the refugee camps pregnant women are encouraged to be registered in the health centre as early as three months for antenatal screening and iron/chloroquine prophylaxis. Total of 3594 women were newly registered in the camps in 1997 while 3222 deliveries have been assisted in the same period. The figure of 17462 in table (X) refers to a cumulative figure of monthly reports from the camps where same women were counted more than once.

Attendance of the antenatal clinic for all camps is 80%. This ranges from 100% in Wad Sharifi camp to 20% in Um/Rakuba and Abuda camps. Generally, antenatal attendance is higher in the reception centres where supplementary feeding is provided to the pregnant women than in the settlements the feeding is limited to children only.

54 (1.5%) out of the 3594 women registered for antenatal in the camp in 1997 have had spontaneous abortions while 45 (1.3%) were referred to hospitals outside of the camps for heavy bleeding. 13 mothers have passed away because of pregnancy related reasons, corresponding to maternal mortality rate of 399/100,000 live births.

Crude Birth Rate of 20/1000 was reported from the refugee camps in 1997 which is half of the rate (40/1000) estimated for the Sudan. The lower rate in the camps is more likely to be due to under reporting since the demographic structure of the two populations are similar and the coverage of the family planning in the camps is rather lower than the one estimated for the Sudan. 2429 (75%) of the deliveries took place in the homes while the rest 828 (25%) were assisted in the clinics in the camps or at the referral hospitals. 71% of the live births were covered with 3TT. 5.7% of the babies were born with low birth weight of less than 250gms. 71 (2.2%) of the deliveries were still births. Only 20 neonatal deaths, corresponding to a neonatal mortality rate of 6.14/1000 live births, were reported from the camps. This suggests that there were gross under reporting of neonatal deaths in the camps in 1997.

4.2 Family planning:

Although much effort was made in training staff and restructuring delivery system of family planing services in the camps in 1997, the coverage remained low; 1.3% of the target population compared to 10% estimated for Sudan. Prevalence of contraceptive use is slightly higher in the Ethiopian than in Eritreans camps. For example, birth spacing is not accepted at all in Um/Gargur which is populated by Eritreans because of strong cultural and religious believes of the refugees against FP. Trainers from the Federal Ministry of Health gave a one week course to MCH health workers in 1997 on how to operate family planning programmes in the camps. Family planning guideline which was distributed in the camp in 1996 was promoted among the medical teams. However, the absence of an impact in the prevalence rate probably reflects lack of proper outside supervision of the activities in the camps.

86% of the contraceptive acceptors used combined pill while only 5% used progesterone injections and the rest 9% used other methods including IUD and condoms..

4.3 Control of Diarrhoea disease programme:

Diarrhoea is the second most important cause of death in the camps and both mortality and morbidity rates due to the disease rises in May to June each year. The CDD programme aims early dehydration at home, supported by a system of ORT corners and inpatient departments for those children with moderate and severe dehydration. In 1997 a total of 33271 children with diarrhoea has received care in the camps. 25687 (77%) were mild cases, 6757 (20%) had moderate dehydration and 827 (3.0%) were with severe dehydration. Continued close supervision of the programme is necessary to maintain the current satisfactory CDD activities in the camps. The programme should ensure that adequate organisational preparedness and prepositioning of necessary supplies are made in each year to control seasonal increase of the incidence of diarrhoea in the camps.

4.4 Immunisation:

Vaccination against the six immunizable diseases is provided to the refugees in the camps and to local population who live in the vicinity. Vaccine, syringes and needles are provided by EPI programme in the States hosting refugees. However, regular shortage of one or the other of these items was common in 1997 as in the previous years. The frequent occurrence of the shortages have necessitated the refugee programme to keep its own contingency supplies in the central pharmacy in order to the cope with the situation.

4044 children under one years of age were registered in the camps in 1997. Table (below) provides immunisation coverage of the children. The coverage suggest generally that the programme has achieved its immunisation target of 80%. Also out of 5470 women registered for tetanus toxoid vaccinations, 2829 (51.7%) have received TT1 and 2641 (48.3) received TT2. This level of coverage is far below the target of 80% and it is recommended that a review and reorganisation of this activity should be carried in 1998 to increase coverage of tetanus toxoid among the child bearing age in the camps.

Table; Number of vaccinations and % of the target under 1 Year of age (4044).

% of the target

Vaccination coverage survey result which was carried out in the camps in conjunction with the nutrition survey of 1997 indicate the following coverage in the camps:

Measles %
Wad Sharifi

A limitation of the survey is the age range of the children in the sample which was between 12-60 months instead of 23-36 months. This probably means that the status of immunisation of many children was determined based on mothers recall rather than on immunisation records which could introduce recall bias in the result of the survey. However, it is apparent that the coverage of Um/Rakuba, Fau5 and Aburakham (measles) are well below those of other camps. Um/Rakuba camp had measles outbreak in 1997 due to a breakdown of the immunisation and other MCH health services in the camp for more than 6 months. It should be noted from the table that the coverage of some of the other camps are as well marginally below the target of 80% in one or more of the vaccinations. This latter finding should not be taken lightly as further slight decrease of the herd immunity in these camps could led to a preventable outbreak of immunizable diseases.

4.5 HIV/AIDS control programme

The exact prevalence of HIV/AID in the refugee population is not known, Sentinel data are by the State hospitals from HIV blood transfusion screening in Gedaref and Kassala but they are not available.

Few cases of full blown AIDS had been reported from the camps and they were actually refugees who moved from Urban towns in search of medical care in the camps.

Health education on modes of HIV transmission, condom distribution and universal precautions in the health facilities were the three main activities of HIV programme in the camps. Health education pamphlets on prevention of HIV transmission and care of AIDs patients were produced in Amharic to support ongoing activities in the camps.

The refugee HIV/AIDS activities are closely co-ordinated with Sudan National AIDS Programme which has an overall responsibility of the control of the diseases for the whole country. Mutual efforts within the two programmes which have benefited both refugees and local population in Eastern Sudan in 1997 include the following:

SNAP has conducted training to refugee health workers in 1997 on management of STDs in the camps in order to ensure that the provision of the services are streamlined in accordance with the national guidelines on treatment and control of the diseases. In the same period, refugee programme has procured HIV screening kits for the blood banks in the State hospitals in Gedaref and Kassala whose services are used by nationals and refugees alike.

4.6 Nutrition:

Following recommendations made by Joint WFP/UNHCR Food Assessment Mission in 1997, all assisted refugees in non-land based camps will receive full ration starting from July 1998. This means the cereal component of the food basket for the wage based settlements will shift from half to full ration. The decision followed findings of a very marginal house hold food security in most of the camps by SCF-UK in a survey which had been conducted in 1997.

For the same reason, the FAM mission has also recommended expanding supplementary feeding of pregnant/lactating women, which is limited to the reception centres, to all the camps from Mid 1998.

Table: Food Basket in the land based nd non-land based camps

Food commodities
Settlements without agricultural land
Land based settlements with 5 Feddans
Land based settlement with 10 feddans
68 (13%)
42 (13%)
42 (13%)
  • The ration of land based camps with 10 Feddans will be gradually reduced during 1999.

The results of 1997 nutrition survey in the camps, together with those from the two previous years, are presented in the table below.

Table: Nutrition survey result for 1995,1996 and 1997. Malnutrition rate is percent less than 80% median w/h.

K Girba
Kilo 26

Note: The rate of malnutrition in Shagarab camp in July 1996 was 21.7% w/h median. But after the introduction of blanket feeding for all <5children in the camp for 3 months the rate fell down to 14.4%.

The picture which could be deduced from the table is that camps with a population of around 10,000 or more are generally worse than the others, perhaps reflecting that an increase of the competition of the refugees in the big camps for limited local resources has a negative impact on the status of malnutrition of the concerned communities.

Nutrition surveys which were conducted in Gedaref State in 1995 and 1996 showed similar rates of global malnutrition. See below.

Gedaref State 1995,1996

Malnutrition Rate


The above finding suggest that the nutrition status of the local population is similar to that of the refugees. It appears that the level of malnutrition in the local population has drastically went up after 1994 when a survey carried out in Gedaref indicated a global malnutrition of 4% less than 80% w/h median. The reason for the up ward surge of the malnutrition is not known, but it could be related to a general decline of the economy of the local population in the last several years.

Supplementary feeding programme in the camps covers children under five years, pregnant/lactating women in the reception centres, tuberculosis patients in the intensive phase of treatment and social/medical cases who are referred to the feeding centres by medical teams.

As is observed during supervisory visits to the camps in 1997, many children in the SFP/TFP stayed in the programme for prolonged period of time. Often admission and discharge criteria were not strictly applied across all feeding centres and failure of weight gain of the children in the programmes is not investigated routinely. In addition, it was found in 1997 survey that 40% of the malnourished children in the sample were not actually registered in the feeding programme.

These findings indicate that the need to increase supervision of this programme and underline the importance of strengthening outreach component of the programme in order to improve the effectiveness of feeding centres in the camps.

4.7 Central Pharmacy:

International NGOs were procuring medical supplies on their own. After the phasing out of these NGOs from the refugee services, procurement, storage and distribution of essential drugs and medical equipment were centralised under the COR Health Unit to cut cost as well as to ensure flaw of medical supplies to the camps. The pharmacy which was then serving for a few camps under COR Health Unit has expanded its responsibility to all the 18 camps by mid 1996.

The yearly requirement of medical supplies in the programme is jointly assessed by COR and UNHCR. Then, UNHCR internationally procures the supplies which are then stored in the central pharmacy from where medical teams get their allocations once every 2 months based on a quota system. With close monitoring from UNHCR, the pharmacy has fulfilled its role reasonably well in the last one and half years since the start of the new arrangement.

However, the pharmacy faced the following challenges.

A. While the work load of the pharmacy has increased tremendously with the introduction of the new arrangement, the staffing level remained the same. Two refugees who had been trained as Assistant Pharmacists in the past years have continued to bear all the burden of the increased workload in the past 2 years without even having support staff such as cleaners. Several attempts were made for the transfer of more staff to the pharmacy but have failed amid an ongoing dispute between COR and UNHCR over the staffing level of COR. This has undermined the staffing needs of the pharmacy and has seriously affected its performance. Stock cards are hardly updated on time as the staff are often busy in preparing orders of the 18 medical teams in the camps. More importantly, the staff of the central pharmacy have never got the time to go to the camp pharmacies for supervision and support.

B. Although the quota of medicines which was established for the camps is based on WHO allocations for emergencies and is, therefore, considered generous for a stabilised programme like the one in Sudan, medical teams have continuously complained of shortage of medicines in the camps. The shortage are due to combination of several factors. Local population in the vicinity of the refugee camps, who are some times equal or more than the refugees, seek health care in the refugee clinics. These has over stretched the allocations of medicines in some of the camps. On the other hand, over prescription of medicines which is common in all the camps is believed to be contributing significantly to the shortages.

Although, an increase of the quota of the commonly used medicines is planned early in 1998 to meet some of the demands, this move alone will not be sufficient to solve the problem of the shortage. It is, therefore, crucial that the pharmacy code of conduct should be expanded to the camps in order to establish adequate system of recording the incoming and out-going supplies and to regularly update stock cards. However, such an improvement would remain a dream unless staffing level of the central pharmacy is increased. At least a qualified Pharmacist, Assistant Pharmacist and two cleaners are required if the pharmacy could be expected to play its crucial role for the refugee programme.


1. The supervisory role of COR Health Unit in the programme was grossly inadequate in 1997. Supervisory visits of the Health Units to the field were very few and where visits took place they were too far apart to be meaningful to the programme. Breakdown of health services of Um/Rakuba in 1997, without the knowledge of the Health Unit, is a good example. However, lack of supervision and support are evident in the programmes of many other camps where sub-standard services which are outside of the standards and procedures of the refugee programme are provided to the beneficiaries. The most significant challenge in this connection is the high turn over of COR Medical Coordinator coupled by the weak position of the Health Unit within COR compared to other units. What is more worrying is that the experienced staff of the unit have either left or are leaving and are replaced by others who have little experience in refugee public health services. Without a strong and a competent health unit, delivery of an adequate health services to the refugees in the camps is not possible. Therefore, it is crucial that the activities of the Health Unit and the competency and experience of the staff should be reviewed in 1998 with a view to improve the capacity of the Unit in providing technical support to medical teams in the field. The link between the unit and the Ministry of Health which is currently limited to consultations should be strengthened further to a level of accountability.

2. The disparity of cost sharing mechanism between the two health systems is not only attracting many local patients seeking medical care in the refugee camps but the free services in the refugee camps is vertical to the national policy of fee-for-services in the health services. Therefore, introduction of an affordable cost sharing mechanism in the refugee programme should be seriously considered by UNHCR and COR in 1998. This matter was discussed several times in the VOLAG meetings and COR Khartoum has approved in principle for the medical teams to explore practical ways the system could be introduced in the refugee programme. Therefore, UNHCR should pursue the matter in the VOLAG meetings to establish practical criteria for the charge of the fees and mechanisms of using the funds generated by the system.

3. Mortality and morbidity data of 1997 indicates that the health status of the refugees is better than those of the Sudanese population. However, some indicators such as neonatal mortality rate are indeed very low, suggesting that perhaps there is a gross under reporting of the data from the camps. In this connection, methods of collecting, recording, and reporting of the data should be reviewed thoroughly in 1998 with a view of validating the low values of the health indicators in the refugee camps. Epidemiology department of FMOH could be approached through WHO Office in Khartoum to do this exercise.

4. The number (3594) of pregnant women registered in the antenatal programme falls far behind the one which is expected from a similar population in developing countries. Based on the refugee population of 134,639 and crude birth rate of 35/1000, about 4712 pregnant women are expected in the camps alone. The discrepancy could be explained by some of the pregnant women who are registered in the antenatal clinics or by scenarios where the population in the camps are inflated. In either case it is important the antenatal programme to find out if the programme is reaching all pregnant women in the camps. A sample surveys in the some of the section in the camps and consultation with the TBAs should be clarify the matter.

Although significant inputs were made in 1997 in terms of training and establishing procedures, coverage of family planning remains low in the refugee camps. Lack of supervision and follow up of the activities in the field by COR Health Unit probably explains the discrepancy in coverage between the refugee and national FP programmes. It is, therefore, important that following the assessment of UNFPA on family planning programme in the camps, plan of action should be developed by UNHCR/COR based on the findings of the mission. Linking the family planning in the camps to the national FP in the States should be considered.

5. Quite a number of refresher courses were provided to the refugee health workers in 1997. However, their impact on the programme has not been fully documented. In the future, the process of identifying training needs of the programme should be contributed by the medical teams in the field and the delivery and the outcome of the training should be documented and followed up with a plan of action prepared on the basis of the recommendations of the participants.

6. Diarrhoea is a common cause of morbidity and mortality in the refugee camps similar to other developing communities. Control of diarrhoea disease activities in the camps was successful in 1997. It was based on early rehydration of the children and referral of severe cases to hospitals within and outside refugee camps. However, 1997 inputs should be consolidated in 1998 by ensuring medical teams are prepared for the seasonal increase of the diarrhoea incidence in the camps and by maintaining current activities of ORT corners in the camps.

7. Vector control programme should be reviewed based on the findings of the medical entomologist who visited the programme in late 1997. A full report of the mission is expected to become available by mid 1998. Future activities of malaria control in the refugee camps should take into account both the policy of the Malaria Department in MOH and recommendations of the above mission report. Emphasis should be put on effective case identification and treatment in the camps which could enable the refugee programme to minimise deaths due to malaria.

8. Immunisation and nutrition surveys in the camps in 1998 should be carried according to the methodology of EPI recommendations and per the nutrition guideline of the Refugee Health unit. A refresher course should be given to the surveyors in preparation to the survey to ensure standardisation of the data collection and repeatability of the methods used.

Mohammed Hassan Qassim
Senior Health Coordinator
Branch Office Khartoum.