VZCZCXRO9021
PP RUEHMA RUEHROV
DE RUEHKH #1181/01 1380737
ZNR UUUUU ZZH
P 180737Z MAY 06
FM AMEMBASSY KHARTOUM
TO RUEHC/SECSTATE WASHDC PRIORITY 2871
INFO RUCNFUR/DARFUR COLLECTIVE PRIORITY

UNCLAS SECTION 01 OF 05 KHARTOUM 001181 
 
SIPDIS 
 
AIDAC 
SIPDIS 
 
STATE FOR AF/SPG, PRM, AND ALSO PASS USAID/W 
USAID FOR DCHA SUDAN TEAM, AF/EA, DCHA 
NAIROBI FOR USAID/DCHA/OFDA, USAID/REDSO, AND FAS 
USMISSION UN ROME 
GENEVA FOR NKYLOH 
NAIROBI FOR SFO 
NSC FOR JMELINE, TSHORTLEY 
USUN FOR TMALY 
BRUSSELS FOR PLERNER 
 
E.O. 12958:  N/A 
TAGS: EAID PREF PGOV PHUM SOCI KAWC SU
SUBJECT: Darfur Health Assessment 
 
------------------- 
Summary and Comment 
------------------- 
 
¶1.  Since the escalation of the conflict in Darfur in 
2004, coordinated efforts within the humanitarian 
community have resulted in substantial improvement in the 
overall health and nutrition situation of conflict- 
affected communities.  These advances are evidenced by a 
declining trend in crude mortality rates (CMR) and rates 
of global acute malnutrition (GAM) to levels below 
emergency thresholds.  The North, South, and West Darfur 
State Ministries of Health (SMoH) are collaborating with 
U.N. and international non-government organization (NGO) 
partners to coordinate health and nutrition 
interventions, conduct cross-sectoral planning 
specifically linked with water and sanitation 
interventions, improve communicable disease and nutrition 
surveillance systems, control communicable diseases, 
provide community health and nutrition education, and 
increase access to primary health care (PHC), including 
reproductive health and nutrition services. 
 
¶2.  However, recent improvements in health and nutrition 
trends may soon be undermined by a variety of factors. 
Reduced donor funding has forced NGOs providing health 
and nutrition services to discontinue essential 
programming activities.  The effectiveness and efficiency 
of humanitarian operations in Darfur are also constrained 
by limited access to insecure areas, frequent population 
movements, logistical shortfalls, high turnover of SMoH 
staff, and increasing government restrictions on 
international aid workers.  Across Darfur, the health 
education sub-sector remains under-prioritized, and is 
often the first health intervention to be downsized as a 
result of reduced donor funding.  Additionally, Darfur's 
resource-intensive curative methodology - which focuses 
on treatment rather than prevention - relies heavily on 
external donor funding, leaving both international 
organizations and the SMoH vulnerable to resource 
pipeline shortfalls.  Furthermore, the standard of care 
offered under the current system may not be transferable 
to local health care providers following the resolution 
of conflict in Darfur. 
 
¶3.   Looking forward, USAID recommends that U.S. 
government (USG) agencies working in the health and 
nutrition sectors of Darfur seek to strengthen existing 
primary health care and nutrition programs by directing 
future funds towards community-based activities in order 
to maintain their sustainability into the future. 
Funding should also be provided to maintain and expand 
health and nutrition early warning and surveillance 
systems, as well as strengthen the expanded program of 
immunizations (EPI) and national immunization days (NID) 
including measles.  Finally, health education initiatives 
focused on preventing acute respiratory infection, 
diarrhea, and malaria have great potential to achieve 
widespread behavior change and improve health throughout 
the region if they are implemented and supervised 
correctly.  End summary and comment. 
 
------------------- 
Visits and Contacts 
------------------- 
 
¶4.  From April 23 to May 3, 2006, a USAID/OFDA Health 
Specialist traveled to North Darfur and South Darfur to 
assess the local health and nutrition situation and 
monitor OFDA-funded health programs in the region.  In 
Khartoum, the health specialist met with a Khartoum-based 
USAID Medical Officer, U.N. agencies including the U.N. 
Children's Fund (UNICEF), U.N. World Health Organization 
(WHO), U.N. World Food Programme (WFP), and U.N. 
Population Fund (UNFPA), and OFDA implementing partners 
Action Contre la Faim (ACF), International Medical Corps 
(IMC), Save the Children-U.S. (SC/US), and World Vision 
International.  In El Fasher, the specialist met with 
representatives from the North Darfur SMoH, Relief 
International (RI), GOAL, UNICEF, WHO, and UNFPA.  While 
in North Darfur, the specialist accompanied GOAL health 
promotion, nutrition, and medical coordinators and a 
 
KHARTOUM 00001181  002 OF 005 
 
 
doctor from the Kutum Ministry of Health (MoH) on a site 
visit to internally displaced person (IDP) camps in Kutum 
and Kassab.  She also accompanied representatives from 
UNICEF, WHO, and the International Rescue Committee (IRC) 
on a site visit to Abu Shouk and Al Salaam IDP camps.  In 
Nyala, the health specialist met with representatives 
from IMC, IRC, the American Refugee Committee (ARC), ACF, 
WHO, and UNICEF and conducted site visits to Kalma camp 
with ACF and IRC, to Al Salam camp with IMC, and to the 
ARC clinic in Nyala. 
 
----------------- 
Health Assessment 
----------------- 
 
¶5.  Coordination:  The health and nutrition sectors are 
coordinated by WHO and UNICEF, respectively.  Both U.N. 
agencies are functioning appropriately as sector leads. 
However, coordination for the Health Education sub-sector 
is weak, with a failure to standardize methodologies 
leading to erratic use of information materials, 
variations in training methodology, and inadequate 
community follow-up for behavior change.  Funding 
shortfalls which have forced WHO to cut human resources 
will significantly weaken regional coordination 
mechanisms and reduce WHO's ability to support Darfur's 
SMoH health surveillance and disease prevention 
activities.  Funding shortfalls have also resulted in 
program cutbacks in critical resources such as community 
health workers, community based services, and knowledge 
surveys. 
 
¶6.  Health Surveillance, Trends, and Capacity:  According 
to WHO, Darfur's CMR of 0.46/10,000/day and under 5 
mortality rate (U5MR) of 0.79/10,000/day are both below 
the emergency threshold levels of 1/10,000/day and 
2/10,000/day percent established by the Sphere Project. 
The WHO-supported Early Warning and Alert Response System 
(EWARS) for reportable diseases has improved local 
capacity to detect communicable disease incidents and 
trends in many of Darfur's IDP camps.  However, the 
reporting rate declined from 66 percent to 40 percent in 
2005 as a result of insecurity, reduced humanitarian 
presence, and IDP population movements.  Routine 
surveillance in areas not supported by international NGOs 
remains challenging due to continued insecurity and the 
logistics requirements needed to maintain ongoing data 
collection activities.  Laboratory facilities lack 
necessary supplies and transportation challenges lead to 
difficulties in the proper collection and analysis of 
samples.  Darfur's SMoH capacity for independent 
operations is constrained by a limited budget, and the 
general scarcity of human resources, equipment, and 
logistics capacity.  Thus, local authorities rely heavily 
on international partners for health surveillance as well 
as disease prevention and treatment. 
 
¶7.  Morbidity and Mortality:  According to WHO, the 
leading cause of mortality in Darfur across all age 
ranges is acute respiratory infection (ARI).  Diarrhea 
(19 percent in North Darfur and 14 percent in South 
Darfur) and acute respiratory tract infections (ARI) (31 
percent in North Darfur and 25 percent in South Darfur) 
account for the majority of the current morbidity rates 
for children less than 5 years of age.  The current all 
age group malaria morbidity rate of 4 percent is expected 
to increase between June and September as a result of 
impending seasonal rains.  Outbreaks of mumps and 
seasonal cases of meningitis in 2005 and 2006 were both 
controlled by rapid detection and response. 
 
¶8.  Preventive Medicine:  Routine EPI coverage for 
diphtheria, pertussis, and tetanus in children less than 
one year of age among target populations has improved to 
61 percent in the third quarter of 2005 (from 32 percent 
in the first quarter of 2005).  Though vitamin A, iodine, 
and de-worming medications are not routinely administered 
under the EPI program, these items are distributed to 
children during irregularly scheduled National 
Immunization Days (NID).  Measles and vitamin A coverage 
in UNICEF's target areas is 73 percent and 86 percent 
respectively.  Darfur's EPI program is currently facing 
 
KHARTOUM 00001181  003 OF 005 
 
 
coverage gaps due to general insecurity, lack of 
resources, and difficulty in maintaining cold-chain 
storage and transport of immunizations. 
 
¶9.  Environmental Health:  In an effort to improve 
management of response to public health emergencies in 
Darfur, WHO has adopted a system to correlate 
environmental health indicators (water quality 
management, solid waste management, and vector control) 
with communicable disease control and prevention 
activities.  This cross-sectoral link has allowed for 
rapid detection of disease, identification of the disease 
source, and enabled immediate intervention to stop 
further disease transmission at the onset of an outbreak. 
As a result, the Darfur region has experienced fewer 
disease outbreaks than the rest of Sudan.  Resource and 
funding shortfalls necessitating reduced staffing for 
epidemiologists and environmental health threaten this 
critical linkage. 
 
¶10.  Primary Health Care Delivery:  According to OCHA, 
access to PHC services in target communities is currently 
at 80 percent.  However, health and nutrition services in 
IDP camps throughout Darfur function on a clinically 
based methodology that is unsustainable for both Darfur's 
State Ministries of Health and the international 
community.  Diagnosis and treatment of diseases in camps 
is difficult to assess, but the USAID health specialist 
found extensive evidence of costly health care practices 
such as unwarranted drug prescriptions, over- 
administration of IV/IM drugs, extended length of in- 
patient care, and ineffective triage.  Darfur's State 
Ministries of Health have adopted the Integrated 
Management of Childhood Illnesses (IMCI) protocol. 
However, the USAID health specialist was unable to find 
these guidelines at any of the clinics she visited during 
her time in Darfur.  NGOs provide most out-patient 
referrals while WHO funds most hospital and medical 
logistics activities.  NGOs managing critical drug 
supplies reported infrequent shortages of essential 
medicines.  IDPs are currently receiving health care free 
of charge, but the international community is evaluating 
beneficiary cost-sharing mechanisms to create a more 
sustainable system which can eventually be transferred to 
Darfur's State Ministries of Health. 
 
¶11.  Reproductive Health:  Reproductive health care 
services, including antenatal, delivery, and post-natal 
care, are available at hospitals and NGO-supported health 
facilities in Darfur's major population centers.  The 
region's maternal mortality ratio is currently estimated 
at 630 maternal deaths/100,000 live births.  (Note:  This 
estimate is based on incomplete data collected from 
hospitals and NGO clinics.  Eighty percent of women in 
Darfur continue to deliver at home.)  Safe motherhood 
services are available to 60 percent of women of 
childbearing age in UNFPA-targeted communities. 
 
¶12.  Malaria:  The regional annual malaria prevalence 
rate peaks shortly after the rainy season.  The control 
strategy for malaria in Darfur consists of clinical 
treatment with appropriate antibiotics (combined 
therapy), distribution of long-lasting insecticide 
treated bed nets, and the use of environmental control 
measures such as risk mapping and insecticides in IDP 
camps during the peak malaria season.  Bed nets are 
currently available to only 41.6 percent of targeted 
households, and their appropriate use in the home has not 
been documented at the community level. 
 
¶13.  HIV/AIDS and SGBV:  The prevalence of HIV/AIDS in 
Darfur is currently estimated at 2.7 percent.  Though 
current testing rates are very low (only 16 people were 
tested in El Fasher in the last 2 years), OFDA 
implementing partners are beginning to increase HIV/AIDS 
education and prevention activities.  Advocacy by the 
international community has improved case management and 
treatment guidelines for victims of sexual and gender 
based violence (SGBV).  State Ministries of Health are 
currently reviewing SGBV management Protocols drafted by 
the MOH and the international community.  UNFPA provides 
rape kits to NGOs for medical management.  However, there 
 
KHARTOUM 00001181  004 OF 005 
 
 
is currently no universally recognized SGBV surveillance 
mechanism for Darfur and NGOs have encountered difficulty 
in accessing post exposure prophylaxis (PEP). 
 
-------------------- 
Nutrition Assessment 
-------------------- 
 
¶14.  Trends:  According to the December 2005 Darfur 
Emergency Food Security and Nutrition Assessment 
published by WFP, UNICEF, and the U.N. Food and 
Agriculture Organization (FAO) in cooperation with 
Sudan's Government of National Unity (GNU), the nutrition 
situation in Darfur had improved and stabilized over the 
course of 2005.  The prevalence rate of GAM in children 6- 
59 months of age has decreased from 21.8 percent in 2004 
to 11.9 percent as of September 2005 and severe acute 
malnutrition (SAM) has decreased from 3.9 percent in 2004 
to 1.4 as of September 2005.  The report attributed 
improvements in nutrition indicators to improved food 
security, lack of disease outbreaks, and the 
establishment of a functioning nutritional surveillance 
system. 
 
¶15.  Surveillance:  UNICEF collects nutritional 
information by conducting standard 30 x 30 surveys and 
coordinating routine nutrition surveillance at 12 urban 
feeding centers or rural sentinel sites in each of 
Darfur's three states.  Recent NGO assessment surveys 
indicate that pockets of malnutrition persist in North 
Darfur.  Additionally, the recent improvement in 
nutrition trends in Darfur is now threatened by a 50 
percent reduction in food rations which coincides with 
the beginning of the regional hunger season. 
Micronutrient deficiencies including vitamin A, iron, and 
iodine are prevalent in children and women of 
reproductive age.  Funding shortfalls resulting in 
reduced humanitarian presence will likely result in 
significant information gaps and undetected pockets of 
malnutrition throughout the area over the coming hunger 
season. 
 
¶16.  Feeding Programs:  Admission rates to selective 
feeding programs have declined to less than half the 
number of admissions recorded in May 2005.  Community 
therapeutic care (CTC) is being implemented in 80 percent 
of selective feeding programs, but to varying degrees by 
OFDA's various implementing partners.  CTC protocols are 
not standardized, training is costly and therefore 
inaccessible, and the State Ministries of Health 
administer traditional more costly TFCs (note: USAID/OFDA 
and Global Health are planning to support CTC training in 
several regions in Africa including Sudan).   Cure rates, 
mortality rates, and default rates for therapeutic 
feeding centers (TFCs) are consistent with Sphere 
standards.  However, the supplementary feeding center 
(SFC) default rate of 39 percent is more than twice the 
international standard of 15 percent established under 
Sphere standards.  The high SFC default rate may be 
linked to a general dissatisfaction with the corn soy 
blend (CSB) distributed in many feeding programs, 
maternal time constraints, or population movements linked 
to a variety of local factors.  Exclusive breastfeeding 
for children less than 6 months old is above 65 percent. 
Health and nutrition education is provided at community 
clinics but requires routine follow-up. 
 
--------------------------------------------- ---------- 
Recent Health and Nutrition Gains Threatened by Funding 
Cuts 
--------------------------------------------- ---------- 
 
¶17.  USAID should strengthen existing health programs in 
Darfur prior to expanding health services into rural 
communities.  Currently, NGOs and Darfur's State 
Ministries of Health do not have adequate financial and 
technical capacity and are struggling to ensure the 
continued health of the people of Darfur. 
 
¶18.  USAID Health Specialist recommends the following 
course of action to consolidate, stabilize, and advance 
health and nutrition in Darfur: 
 
KHARTOUM 00001181  005 OF 005 
 
 
 
a)  Coordination:  Support WHO and UNICEF to staff and 
coordinate health sector humanitarian interventions in 
Darfur, including efforts to control communicable 
diseases and monitor environmental health, in order to 
avoid impending gaps due to funding shortfalls. 
 
b)  Surveillance:  Support WHO to continue disease 
surveillance via EWARS and build the capacity of Darfur's 
State Ministries of Health to ultimately assume 
responsibility for managing this important system. 
Current methods of data collected through NGOs operating 
in IDP camps and host communities should be expanded to 
include non-camp populations as capacity allows.  Expand 
Darfur's nutritional surveillance system - including 
surveys, feeding center data, and sentinel site 
information - as capacity allows.  These systems are 
critical for early detection and response to public 
health emergencies in order to avoid massive disease 
outbreaks and increases in malnutrition rates. 
 
c)  Primary Health Care:  Support existing basic PHC 
services in IDP camps and affected host communities. 
Where possible, support a local PHC structure that serves 
both IDP sites and host communities to improve capacity 
of Darfur's local health systems.  Strongly promote the 
implementation of cost-effective community-based methods 
such as clinical and community IMCI. Improve triage 
procedures and strengthen coordination between health 
NGOs to reduce patient load as well as support community 
based therapy when appropriate. Support routine EPI and 
NIDs including vitamin A, de-worming medicine, and iodine 
distributions.  Continue funding commodities such as 
basic essential medicines, vaccines, medical supplies, 
and nutritional products containing micronutrients. 
Continue to build local SMoH capacity to manage health 
finances, medical training, and drug inventory and 
control systems. 
 
d)  Selective Feeding:  Provide technical support to 
increase health sector and community capacity to 
implement Community Therapeutic Care (CTC) programs in an 
effort to decrease long, costly inpatient nutritional 
care (note: this will be funded by USAID).  Investigate 
the high SFC default rate and apply lessons learned to 
improve program efficacy. 
 
e)  Health Promotion:  Monitor community based health and 
nutrition interventions to closely measure behavioral 
change. Strengthen community health and hygiene promotion 
activities by supporting sub-sector coordination and 
funding collaborative joint knowledge, attitudes, and 
practices (KAP) surveys.  Encourage NGO collaboration to 
use these KAP surveys to formulate community training 
guidelines, standard training protocols, and information, 
education and communication (IEC) materials.  Support the 
development of a joint monitoring system to follow up on 
KAP surveys and measure behavioral change.  The 
association between positive behavioral change and the 
corresponding decrease in disease rates cannot be 
overemphasized. Maintain and prioritize transferable 
health interventions - including malaria prevention, 
diarrhea prevention, health seeking behavior, home based 
care, safe feeding practices, growth monitoring, and 
breastfeeding. Avoid expansion of medical clinics into 
new communities and focus attention to build and sustain 
IDP knowledge of community health best practices. 
 
HUME