04 April 2023
The Republic of Sudan is the third largest country in Africa with a population of about 45 million. Since 2002, the Global Fund has disbursed nearly US$822 million to support the fight against HIV, tuberculosis (TB) and malaria in the country. The Global Fund has classified Sudan as a challenging operating environment (COE) due to the country’s history of civil war and political instability. Limited domestic resources and sanctions against the Sudanese government by the international community have contributed to low donor funding and high dependence on the Global Fund to fight the three diseases. Hyperinflation has led to the downgrading of the Sudanese Pound and contributed to Sudan’s status as a low-income country. Natural disasters and weak infrastructure also continuously undermine the implementation of Global Fund grants.
The flexibility, innovation, and partnership principles that the Global Fund COE policy allows have yet to be effectively leveraged in Sudan. Although the OIG noted considerable improvement in financial management, innovative and flexible solutions are ineffective to address data quality challenges, to increase the use of malaria rapid diagnostic tests, to improve vector control interventions, or to increase grant oversight beyond the state level. The use of a “developmental approach” during humanitarian emergencies in Sudan has proven ineffective. Grant performance remains below expectations, even after considering the impact of the pandemic and the risk mitigation measures put in place. Furthermore, some risk mitigation measures for the portfolio are not adequately addressing the challenges identified by both the OIG and the Secretariat, while implementation of other measures has yet to start. The adequacy and effectiveness of implementation, oversight and assurance arrangements needs significant improvement.
While recognizing the impact of COVID-19 health system disruptions on the programmatic performance, implementation approaches are not yielding the expected results. As a result, Sudan is currently losing ground in the fight against malaria and HIV. In 2021, the estimated malaria cases and deaths in the country had increased over 52% and 64% respectively since 2016. The OIG noted insufficient planning and coordination of malaria vector control activities with distribution delays during the long-lasting insecticidal nets (LLINs) mass campaign. No substitute was agreed when needed for indoor residual spraying activities and the treatment of malaria cases was also inefficient. Progress on the UNAIDS cascade has been slow, the number of people living with HIV who know their status went from 37% to 45% between 2019 and 2021. The design model for testing is inefficient, negatively impacting the positivity yield among key populations. Inaccurate data, as well as weak oversight over activities, also undermines programs. Implementation of HIV and malaria interventions to ensure access to quality services by beneficiaries need significant improvement.
Improvements to the supply chain management system for health commodities in Sudan have been slow to progress since the last audit in 2019. The supply chain is not integrated and is managed by several stakeholders with diluted accountability and ownership. There is limited oversight over the supply chain at all levels, with limited availability and traceability of health commodities at the locality and health facility level, exacerbated by low human resource capacity. All these issues have contributed to material stock-outs and expiries of medicines. The design and effectiveness of supply chain mechanisms to ensure timely and uninterrupted availability of health and non-health commodities is ineffective.