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The Sudan Health Cluster is responding to the health needs of people across Sudan, where a protracted crisis and multiple new emergencies are applying further pressure to an already fragile health system. In addition to the COVID-19 emergency, Sudan is facing the reemergence of polio after previously being declared polio-free, malaria has reached epidemic-level in 11 out of the 18 states of Sudan and the worst floods in its recorded history could be at the base of further water- and vector-borne outbreaks. These new events come on top of a protracted crises in Sudan due to civil wars and prolonged conflict that have generated population displacement and strained the already fragile health system. In the current funding climate, the Sudan Health Cluster is utilizing its limited resources to maintain continuity in essential health services.

Even meeting the basic health needs of the population in Sudan is a challenge for the Health Cluster. It is estimated that 8.6 million people are in need of lifesaving and life sustaining health activities, according to the Sudan Humanitarian Needs Assessment for 2020. Sudan hosts 1.1 million refugees from neighbouring countries and 1.8 million internally displaced people (IDPs). However, there are not sufficient human resources in the country to address the health needs of the affected population. The World Bank and the WHO recommendations to ensure universal health coverage propose a target of 4.45 healthcare professionals (doctors, nurses and midwives) per 1 000 population, while Sudan’s current capacity allows for only 0.81 per 1 000 population. Furthermore, the additional health expenditures related to COVID-19 (personal protective equipment and supplies to support infection prevention and control measures) and global shortages and price fluctuations have led to an unpredictable and challenging funding landscape.

A coordinated response across partners is of paramount importance to leverage the strengths and available resources of each partner operating in Sudan effectively without any duplication of efforts. “Health Cluster partners are supporting 60% of basic service provision in some areas of Sudan, such as greater Darfur,” states Health Cluster Coordinator Kais Aldairi, continuing “coordination is key to addressing multiple emergencies in a way that ensures the best possible coverage given limited resources.” To address the COVID-19 emergency, the Health Cluster has prioritized essential health care services to ensure that the decrease in service utilization does not result in further outbreaks or negative health outcomes. In response to the malaria outbreak and threat of a cholera outbreak, the Health Cluster is pre-positioning supplies and operating via mobile clinics to reach areas that have become inaccessible due to flooding. Lastly, the Health Cluster is planning to coordinate partners’ efforts contributing to national vaccination campaigns to combat the reemergence of polio and the reduction in routine immunizations for children under five years of age.

Maintaining essential health services in the COVID-19 context

At the start of the COVID-19 outbreak, public officials faced challenges in combatting the fear, stigma and misinformation to ensure patients with symptoms corresponding to those of suspected or confirmed cases could be tested and receive appropriate care. The movement restrictions and lockdown measures disrupted the ability to deliver both COVID-19 and other essential health care services. These barriers plus the economic impact of the lockdowns and the supply shortages of fuel and medical supplies generated a noticeable decline in primary service utilization.

In response, the Country Preparedness and Response Plan (CPRP) was developed by the Health Cluster and later adopted by the Humanitarian Country Team and United Nations Country Team as the country plan to support the national response to COVID-19. The strategy focused on maternal and child health, expanding immunizations and shoring up preparedness for the rainy season and any related vector and water-borne disease outbreaks. Currently 37 Health Cluster partners support service delivery of lifesaving and life sustaining essential health services in 16 states of Sudan. In the first half of 2020, partners supported 2.9 million outpatient consultations, assisted 87 000 deliveries and 9 000 cases referred to higher levels of care through 93 mobile clinics and ambulances. Partners trained 6 478 health workers on disease surveillance and reporting, rapid response to emergencies and gender-based violence (GBV) case management.

Coordinated approach to multiple hazards

According to the Sudan Humanitarian Aid Commission (HAC), nearly 830 000 people have been affected by floods in 17 out of the 18 states of Sudan. Given the increased breeding sites, the population displacements and the compromised water sources, there is a significant risk of a high incidence of water-borne and vector diseases. Cholera and malaria are of primary concern, particularly since malaria has already breached the epidemic threshold if 15 states and could worsen. Other viral diseases that are transmitted by vectors (arbovirus), including dengue fever, chikungunya, Rift Valley fever (RFV) and others are also expected to increase as a result of the flooding.

The Sudan Health Cluster has been preparing for a particularly challenging rainy season and the anticipated health consequences since April 2020 after the release of the Multi-Hazard Plan from the Ministry of Health, UNICEF and WHO. The WHO pre-positioned 29 cholera kits (20 more in the pipeline) to treat 5 000 cases to facilitate swift action if any cholera cases are reported. The Health Cluster is also collaborating closely with the WASH partners to address the high number of samples showing low or absent chlorine levels (54%) and bacteriological contamination (51%). As recommended in the Cholera Joint Operational Framework from the Global Health Cluster and the Global Water, Sanitation and Hygiene (WASH) Cluster, the WHO is supporting the identification of cholera hot spots which will inform the implementation of the national cholera response plan.

Since April 2020, the Sudan Health Cluster worked with partners to implement the multi-hazard health plan and distribute medical supplies that cover 1.2 million people. Supporting partners include national NGOs such as al Manar Voluntary Organization (AMVO) and Global Aid Hand (GAH), as well as INGOs with local presence such as Care International, American Refugee Committee, Relief International and International Medical Corps. The WHO has deployed 14 new mobile health clinics to support Blue Nile, North Darfur, Central Darfur, Red Sea, Kassala and Khartoum, with other Health Cluster partners supporting 40 other existing mobile health clinics. The WHO has procured and is organizing the distribution of 266 Interagency Emergency Health Kits (IEHKs) to support Malaria treatment and other health needs, with each kit serving 10 000 people for 3 months. UNICEF also is preparing to distribute 18 IEHKs and 7 acute watery diarrhea (AWD) kits. However, there are still significant shortages in malaria supplies to address the current endemic levels, with the Ministry of Health reporting difficulties in distributing medical supplies due to inaccessible areas after flooding.

Mobilizing partners to increase vaccination coverage

As a result of the COVID-19 outbreak and subsequent movement restrictions and lockdowns, there was an estimated 15% drop in the use of Measles-containing-vaccines (MCVs) during the first quarter of 2020 as compared to the same period the year prior. Most activities planned in the Integrated Management of Childhood Illnesses (IMCI) plan were canceled and there was a 65% decrease in measles vaccination coverage among children under five years of age. Surveillance and testing activities for measles have been hindered by the funding crisis and the movement restrictions, so the Health Cluster has shifted to community-based surveillance and reporting of suspected cases to monitor the outbreak.

In early August, the Ministry of Health reported new cases of Vaccine Derived Poliovirus type 2 ( cVDPV-2) in 11 states of Sudan, the first identified since 2009. This is a multi-country outbreak from the same genetic family of cVDPV2 is circulating in Chad, Sudan and South Sudan. To respond to the cVDPV2 outbreak, the Sudan Health Cluster, WHO and UNICEF launched preparations for a vaccination campaign to cover the children who missed their routine immunizations scheduled earlier in the year. Two national polio vaccine campaigns are planned for the months of October and November, targeting 8.6 million children in each round across Sudan, however it is likely to face significant challenges due to funding shortfalls, seasonal floods and inaccessible areas. The Health Cluster is also mobilizing partners who are supporting health facilities and IDP camps to engage with the community in risk communication and community engagement activities to increase uptake of vaccinations, such as UNICEF through the communication for development (C4D) programme.

Despite the ongoing efforts and commitment of Health Cluster partners, the health sector is still underfunded with only 15% of the HRP appeal received and only 17% of the COVID-19 appeal received. As a result, several key activities have been scaled back, including a reduction in support to COVID-19 isolation centres and rapid response teams. “There is an urgent need to raise an estimated 25 million USD to respond to the urgent health needs of those affected by seasonal floods,” Shares Sudan Health Cluster Coordinator Kais Aldairi, further elaborating, “these funds will allow Sudan to procure essential medicines and supplies to support preventative measures for vaccine-preventable, vector and water-borne diseases.” Coupling the funding gaps with the current easing of national mitigation measures, health officials fear that Sudan may experience a second wave of COVID-19 cases.