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Rising to the Challenge

February 21, 2013


Drawing upon the World Bank-administered Sudan National Multi-Donor Trust Fund, the Decentralized Health System Development Project has helped to improve access to basic health services by conflict-affected and underserved populations. Midwifery training schools, medical kits, and subsidies for free care increased the number of assisted deliveries from 23% in 2010 to 51% in 2012 and the percent of pregnant women attending at least one antenatal consultation increased from 59% to 69% over the same period. The project also supported the training of 2,240 primary health care workers by 2012.


The 2006 Sudan Household Survey showed that an astonishing 1,414 women per 100,000 live births were dying of maternity-related causes in Kassala, Sudan, one of the highest rates in the developing world. The number of trained village midwives was insufficient, risky cases were not being detected and referred to facilities with obstetric surgery, women did not have access to nutritional supplements, and there was little awareness about reproductive health. Additionally, basic infrastructure deficiencies, such as insufficient roads and means of transport, made it difficult to transport at risk mothers to more intensive medical treatment.


In the Kassala state of Sudan, the project supported the establishment of midwifery training schools in towns such as Wagar and Hamashkoraib, where women are typically not allowed to move to the capital for training. The project is also supporting construction of a midwifery school in the town of Kassala, where older midwives can receive continuous training and new students enter a two-year curriculum. The project pays graduates based on their performance, promoting antenatal consultancies, deliveries, and postnatal consultancies assisted by qualified staff, including trained village midwives. Because village midwives receive these incentives from the project, they do not charge for services, opening the option of healthcare to many impoverished women. Graduates also receive a box of medical supplies and instruments including scissors, a thermometer, a blood pressure instrument, anesthetics, and vitamins, all of which are replenished every month.


The project reports the following results in the Kassala state of Sudan:

  • Pregnant women attending at least one antenatal consultation increased from 59% in 2010 to 69% in 2012
  • Births attended by skilled health staff increased from 23% in 2010 to 51% in 2012
  • Approximately 2,240 primary health care workers had been trained by 2012.
  • A set of midwifery training schools were opened in 2010, increasing the number of trained midwives
  • By September 30, 2010, 18 health care facilities were constructed or renovated.
  • Extra nursing training was provided to 40 village midwives in Hamashkoraib, where there is no community health workers to provide first aid or maternity services.
  • The increase of midwives in areas with the least coverage had the greatest impact on results. The following villages saw their number of midwives increase at the following rates from 2006 to 2012:
    - Wagar: seven to 46
    - Hamashkoraib: 0 to 66
    - Rural Kassala: 49 to 68
    - Aroma: 17 to 67
    - Talkuk: 13 to 73

Bank Group Contribution

The Sudan National Multi-Donor Trust Fund contributed US$5 million to expanding access to primary health care services for underserved populations. The trust fund also contributed US$13.4 million to establishing the basis for reform and development of the decentralized health system. The trust fund donors included the Netherlands, Norway, United Kingdom, Canada, European Union, Sweden, Finland, Spain, Germany, Denmark, Italy, Egypt, Iceland, Greece and the World Bank.


Development partners such as the United Nations Children’s Fund (UNICEF), the United Nations Population Fund (UNFPA), the World Health Organization (WHO), and some nongovernmental organizations (NGOs) have participated in improving reproductive health in Sudan.

Moving Forward

UNICEF has adopted this project’s midwives training program as a model and replicated it by establishing a boarding school in 2010 for the training of 40 midwives at a time.


Nora, a young graduate from the Tawaeet training school for midwives, is currently taking additional medical training in Kassala town. She comes from Tagher village, which is about two hours’ drive from Kassala town, and is proud to be the first from her village to serve her community.

“I tell the pregnant women to come for check-ups and I see how their pregnancy is going,” she said. “If I see that there are going to be complications with the delivery, I send them to the hospital, if I see that she can give birth without complications, I help her give birth at home.”