3rd in-depth review mission for NTP November 2008

Background:
The last in-depth review of the Sudan National Tuberculosis Control Programme was carried out in 2004 by the World Health Organisation (WHO), the International Union Against Tuberculosis and Lung Disease (The Union) and the Norwegian Heart and Lung Patient Organisation (LHL). For the last four years the Federal Ministry of Health (FMOH), through its National Tuberculosis Programme (NTP) has made important progress in the fight against tuberculosis in the country. Regular evaluation is the keystone for the NTP progress. In accordance with WHO, the Union and LHL, a new in-depth review was therefore carried out November 10-24, 2008.

Purpose/objective:
The overall objective was to assess progress according to plans since the last review and assess strengths and weaknesses in the NTP to prepare for its development towards quality services and sustainability. The review was limited to the 15 states of North Sudan.

More specific objectives were:
• To assess the progress in the policies and plans in the NTPs five year plan.
• To assess the progress in implementing the recommendations from the last In-depth review in 2004.
• To evaluate the progress made in the strengthening of the NTP, particularly in terms of DOTS expansion and management structure.
• To assess the integration of the NTP in the general health system of Sudan and co-operation with other programmes.
• To critically evaluate the implementation of the agreement between the FMOH and  LHL signed in January 2005.
• To assess the technical support given to the NTP.
• To review the NTP plans for sustainability and focus on quality of services.

Methodology:
The review team had meetings with the Federal Minister of Health, Assistant Undersecretary for Clinical Care, Director General of Preventive Medicine, National reference laboratory and Central Medical Store. The team made site visits to the states of Khartoum, Sennar and Gadarif, including visits to TB Management Units /TBMUs).  Some patients were also interviewed

Key findings:
Main findings
a) Case notification has not increased as planned, but declined and treatment success rate has remained stable between 81% and 84%.
b) A number of TBMUs were already established by 2004 (1 per 100,000 population) and there has been no increase since.
c) The general health system in Sudan faces considerable challenges.   The TB programme therefore retains some functional elements under its own control
d) The Global Fund for AIDS Tuberculosis and Malaria (GFATM) Round 5 and Round 8 will provide substantial funding, including for financial incentive payments to health staff.
Recommendations for main findings
1. SNTP Manager should proceed to re-organise the Central Team to facilitate effectiveness
2. SNTP at Federal level should develop a competence-based human resource development plan
3. The SNTP should make a plan for external TA and should co-ordinate this carefully with the training requirements identified in the human resource development plan. 
4. FMOH should consider a long term strategy to take over incentive payments to staff working within the Primary Health Care (PHC) system.
5. SNTP should consider how the payment of financial incentives can result in strengthening the health system.

Recommendations: The single most important and urgent recommendation was:-
SNTP at Federal and State levels to strengthen and monitor DOT and treatment support by developing clear guidelines and training for each of the following hierarchy of organized and documented treatment support options:
i. Providing DOT and treatment support through all health facilities of the primary health care network
ii. Providing DOT and treatment support through community structures such as volunteers and patient organizations.
iii. Providing DOT and treatment support through guardians
Given the importance of this recommendation, SNTP should seek external technical support for developing these activities in an organized, evaluable and sustainable manner.

Comments from the organisation, if any: The high turn over of not only staff, but also managers og the NTP has meant that the program has not be adequately controlled. The current NTP manager is expected to stay longer and receives in-country backing by a WHO consultant.