Sudan Household health Survey (SHSS) South Darfur technical report 2006

Sudan Household Health Survey, South Darfur State, Final Technical report Draft 2/Page 1 of 38
Federal Ministry of Health
Central Bureau of Statistics
Sudan Household Health Survey
South Darfur State
May 2006
Technical report (Draft 2)
Prepared by:
Dr. Ghaiath Mohamed Abas
Federal State SHHS Manager
E-mail: ghaiathh@sud.emro.who.int
Mob: 0912978652

DISCLAIMER
THIS REPORT REFLECTS THE OPINIONS AND VISIONS OF THE SMT
IN THE SOUTH DARFUR STATE AND DOES NOT REFLECT ANY
OFFICIAL SITUATION OF THE HIGHER RESPONSIBLE COMMITTEES
MANAGING THE SHHS.
EXECUTIVE SUMMARY
Introduction
SHHS is a national Pan-Sudan survey that covers the whole 25 states of the Sudan. It is
considered as one of the biggest health-related projects that take place after the
signature of the CPA, between GoS and SPLM/A.
In the same context, unfortunately, the crisis in Darfur was described in 2004 as the worst
humanitarian situation in the world. As of July 2005, around 3.3 million people -or 50% of
the total population- have been estimated in need of humanitarian assistance. The
international response, slow at the beginning of the crisis, gained momentum in 2004,
when Darfur started drawing political attention, with increasing ledges of the donor
community, growing numbers of humanitarian workers, and an overall good accessibility
to humanitarian aid. Half of the health requirements were funded midway into 2005.
Despite the ambiguity of Darfur states’ status of security and the constraints faced the
peace negotiations mediated by AU, the three states of Darfur, though classified as
hardship areas, were not excluded from the implementation of the SHHS.
Objectives and methods
This survey was jointly prepared and conducted by the FMoH and CBS, in partnership
with the relevant UN agencies. Funding was provided by partner UN agencies and the
GoS. The protocol of the study was submitted to an inclusive peer-review.
Regarding the three Darfur states logistic and technical support was offered by SMOH,
UN partners and other NGOs.
The main objective of the survey was to estimate some of the basic health and health-
related indicators in accessible areas. More specifically, the indicators that the survey
aimed to include:
1. Mortality indicators
2. Maternal Health Indicators
3. Indicators on Marital Status
4. Indicators on family planning
5. Child health indicators
6. Indicators on Immunization
7. Indicators on Nutritional Status
8. Indicators on Child Rights
9. Indirect Health Indictors
10.Indicators on Malaria and HIV/AIDS
These indicators are elaborated in the relevant parts of this report.

The survey used both retrospective and cross-sectional approaches, based on two-stage
cluster sampling. A separate survey was conducted in each State, each targeting the
selected study populations. The clusters were randomly allocated from EPI frame lists of
villages. The second sampling stage used the standard systemic random cluster
selection methodology. A total of 40 clusters of 25 households each was included in each
state. Data were collected anonymously by teams of interviewers with the supervision of
national staff, using a structured pre-piloted questionnaire in Arabic. Data included
deaths, births, migration in/out during the study period, demographic characteristics and
availability of basic goods and services. Data will be analysed separately for each State
and study population, and jointly for all the other states, after weighting for stratum
population size.
Main Constraints and recommendations
Among other constraints, the issue of security and accessibility to most of the selected
areas remained the main constraint. This led to replacement of about 35% of the selected
areas and extension of the duration allocated to the conduction of the survey from 32
days to 45 days. More details are found in the relevant chapter(s).
Any future planning for conducting a survey in Darfur should have clear vision of the
peculiarities of South Darfur; that represents alone half the surface area of whole Greater
Darfur region (equivalent to half the surface area of France). This should include the
number of teams, having clear commitments of partners and have the financial situation
clear beforehand.

LIST OF ACRONYMS
ARC American Relief Commission
AU African Union
CBS Central Bureau of Statistics
CDC Centre for Disease Control and Prevention
CMR Crude mortality rate
CPA Comprehensive Peace Agreement
CRED Centre for Research on the Epidemiology of Disasters
DE Design Effect
DG Director General
EMRO Eastern Mediterranean Regional Office
FMOH Federal Ministry of Health
FSSM Federal State Survey Manager
GoS Government of Sudan
H/E His/Her Excellency
HAC Humanitarian Affairs Commission
ICRC International Committee of the Red Cross
IDPs Internally Displaced Persons
ISA Inshaa Allah, If Allah permits
M & E Monitoring and Evaluation
MDGs Millennium Development Goals
MICS Multiple Indicators Cluster Survey
MOE Ministry of Education
MOHGSS Miinstry of Health ofGevernomant of South Sudan
MOSA Ministry of Social Affiars
NCA Norwegian Church Aid
NGOs Non Governmental Organizations
OCHA Office for Coordination of Humanitarian Affairs
PAPFAM Pan-Arab Family Survey
PPS Probability Proportional to Size
S.N. Serial Number
SHHS Sudan Household Health Survey
SLPM/A Sudan Liberation People’s Movement/ Army
SMOH State Ministry of Health
SMT State Management Team
SSCSE South Sudan Center of Statistics and Evaluation
U/S Undersecretary
U5MR Under five mortality rate
UNDP United Nations Development Programme
UNDSS United Nation Department of Safety and Security
UNFPA United National Population Fund
UNICEF United Nations Children’s Fund
WFP World Food Programme
WHO World Health Organization

ACKNOWLEDGEMENTS
The conduction of the SHHS in South Darfur State was made possible by invaluable
efforts from many partners. Their Excellences the vice-Wali, Dr. Farha Mostafa, and
State Minister of Health, Dr. Abdallatif M. Shareif, together with the DG of SMOH, Dr.
Abdal Gayoum Ibrahim showed their commitment and support all through the conduction
of the survey, starting by training till the last day of implementation of the survey. Our
colleagues in the departments of reproductive health, malaria control, EPI, curative
medicine offered the vehicles our teams for most of the duration of the survey. This effort
was coordinated by the Transport Officer of SMOH, Mr. Irahim Barakat. The locality
commissioners and the administrative officers of all nine localities were very helpful
facilitating the advocacy for the survey and giving the basic information about the
selected clusters.
The police commander of South Darfur State General Omar M. Ali helped in assessing
the security situation of the selected areas.
The UN agencies offices in Nyala had been positive and supportive and helped handling
many problems. Dr. Malik Badawi, SHHS focal person in UNICEF had been always
available in facilitating our movement and facilitated the flight for our team to Aldeain.
Mrs. Sumani and M. Ali from UNFPA had the first step in interpreting their commitment to
practical facilities that helped our work indeed. Dr. MAgdi Kasem, team leader of WHO
Nyala and Dr. Seif Aldeen, WHO Epideiologist offered important technical notes and
were closely following the progress of work. The weekly health coordination meeting in
WHO was a weekly forum for advocacy for the survey among other NGOs.
Other NGOs staff were involved in the preparation and conduct of some logistic and
technical affairs of the survey and it is impossible to name here all of them.
Many community leaders had their major role in facilitating the perception of the
households’ members and facilitated the entrance of our teams to the villages. They
showed hospitality and offered protection when needed.
Finally, the survey would have been impossible without the hard work of many
interviewers, drivers, and camp leaders and, of course, without all the families who
accepted to participate: to them our sincere thank.
To those omitted, our sincere apologies.

Map of Darfur

Table of contents
Executive Summary........................................................ 2
List of Acronyms............................................................. 4
Acknowledgements............................................................ 5
Map of Darfur................................................... 6
Table of Contents............................................................... 16
1. Introduction................................................................. 17
1.1 The SHHS distinguished features
1.2 Rationale and Objectives of the Study
1.3 Contents and Indicators of the Study
2. Implementation and implementation Modalities............... 23
2.1 Team Setting
2.2 Advocacy
2.3 Areas covered and areas replaced
2.4 Situation of needs and their fulfillment
3. Discussion.......................................................... 30
4. Conclusions and Recommendations............................... 33
References..................................................................................... 34
Annexes: …………………………………………………………………..
Maps of South Darfur State (by locality)
English Translation of Household Questionnaire
English Translation of Woman Questionnaire
English Translation of Under5 Questionnaire
English Translation of Community Food Security Questionnaire
English Translation of Community Questionnaire
35

1. Introduction
1.1 The SHHS distinguished features
Sudan Household Health Survey (SHHS) is a unified national study that covers the
whole 25 states and134 localities of the Sudan, 40 segments per State and 25 HH per
segment using systematic random selection, a total of 25000 households for the whole
country. Its idea has started in 2004 as 2 separate surveys: PAPFAM (Pan-Arab
Family Survey) in the North and MICS (Multi-Indicator Cluster Survey) in the South.
This study represents a model of Partnership, as it involved the GoS; (FMOH,
MOHGSS, CBS, SSCSE, MOSA, NCCW, NPC, MOE, W&S), UNICEF, UNFPA, WHO,
WFP,UNDP, USAID and Arab League. It materialized the CPA by a series of meetings
between experts from North and South supported by various partners in Nairobi, Cairo,
Khartoum and Rumbeik. It should be also seen in the context that it paves the way for
the national census (2006).
In Darfur, this survey has further distinguished features. This underdeveloped region of
the Sudan went through recurrent droughts, insufficient investment and spill-over
repercussions from other regional conflicts have exacerbated the already precarious
situation. All these factors have been acknowledged to be at the origin of the recent
phase of the conflict (Polloni 2004, Pantuliano 2004, de Waal 2004 and 2005), which
has been characterized over the last three years by unprecedented levels of violence.
The high level of violence and insecurity has resulted in a huge internal displacement
and in the flight of around 200,000 refugees to the neighbouring Chad. The crisis has
progressively affected nondisplaced communities, whose already stretched resources
and services have suffered from increasing pressures and overall economic
breakdown. As of July 2005, around 3.2 million people, or 50 % of the total population1
in Darfur have been estimated in need of humanitarian assistance.
The number of humanitarian workers has increased from 228 in April 2004 to around
12,500 (national and international) one year later, with 81 NGOs and 13 UN agencies
active in the region (Office of the UN Resident and Humanitarian Coordinator for the
Sudan, July 2005).
As of June 2005, overall accessibility to UN humanitarian aid was estimated at 90%,
being only 77% in the South, the most populous state of the region (ibidem).
1.2 Rationale and objectives of the study
This survey aims at producing national and regional data, to state level, on key
socio-demographic, health, nutrition and food security variables. The selected
1
According to UNFPA & Government estimates of 1999, the pre-conflict Darfur population amounted to
approximately 6.4 million people

indicators were based on core international indicators and aimed at monitoring the
MDGs and other international commitments.
The main objective of the survey was to estimate some of the basic health and health-
related indicators in accessible areas. More specifically, the indicators that the survey
aimed to include:
1. Mortality indicators
2. Maternal Health Indicators
3. Indicators on Marital Status
4. Indicators on family planning
5. Child health indicators
6. Indicators on Immunization
7. Indicators on Nutritional Status
8. Indicators on Child Rights
9. Indirect Health Indictors
10.Indicators on Malaria and HIV/AIDS
1.3 Contents and Indicators of the Study
The Sudan Household Health Survey (SHHS) has five parts: the community
questionnaire, the food security questionnaire, the Household Questionnaire, the
Woman's Questionnaire, and the Under 5 Questionnaire. Each household selected
to participate in the survey will be administered one Household Questionnaire.
Every woman between the ages of 15 and 49 will be administered the Woman's
Questionnaire, and an Under 5 Questionnaire will be completed for each child
under five years of age.
Each questionnaire consists of several modules. Each module contains questions
that ask about a particular topic. The modules are identified by a module name,
and by an abbreviation for the module name. The list that follows shows which
modules are included in each questionnaire, and gives the abbreviations for each
module (in parentheses).
Household Questionnaire
 Household Information Panel (HH)
 Household Listing Form & Education Module (HL)
 Household Income Module (HI)
 Water and Sanitation Module (WS)
 Household Characteristics Module (HC)
 Insecticide-Treated Net Module (TN)
 Salt Iodization Module (SI)
 Final Household Instructions (FH)
Woman's Questionnaire
 Woman’s Information Panel (WM)
 Marriage Module (MA)

 Reproduction and Child Survival Module (RC)
 Live Birth History Table (BH)
 Maternal and Newborn Health Module (MN)
 Tetanus Toxoid Module (TT)
 Contraception Module (CP)
 HIV/AIDS Module (HA)
 Final Woman's Questionnaire Instructions (FW)
Under 5 Questionnaire
 Under-Five Child Information Panel (UF)
 Birth Registration Module (BR)
 Vitamin a Module (VA)
 Care of Illness Module (CA)
 Malaria Module (ML)
 Excreta Disposal Module (EX)
 Breastfeeding Module (BF)
 Immunization Module (IM)
 Anthropometry Module (AN)
One Household Questionnaire will be completed for each household selected to participate in the
survey. The Household Questionnaire may be administered to any adult in the household (anyone in
the household who is 15 years old or older). A brief overview of the contents of each module in the
Household Questionnaire follows.
Household Information Panel (HH)
This module contains information about the household, including identifying information, and
information about how many Woman’s and Under 5 Questionnaires should be and have been
completed for the household. Also included is a place for the interviewer and supervisor to make
notes about the interview and any problems they may have encountered.
Household Listing Form & Education Module (HL)
This is the section of the questionnaire where information is gathered about all the household
members. Everyone in the household should be listed on this listing form. Included on this form are
questions about sex, age, marital status, employment status, and education.
Household Income Module (HI)
This module gathers information on the household’s assets, specifically, livestock, herds, and farm
animals.
Water and Sanitation Module (WS)
This module asks about the main source of water for the household, and asks about the facilities
available to household members. Questions include information on who goes to get the water, how
long it takes to get water, and whether (and how) the water is treated before drinking. Additionally,
questions related to the facilities the household uses to dispose of human waste are included.
Household Characteristics Module (HC)
This module gathers information on the physical structure of the household, including the number of
rooms/tukuls, the materials of the floor and roof, and where (and with what fuel) the cooking is done.

Also included in this module are questions about household items that household members own,
have, or use outside the household.
Insecticide-Treated Net Module (TN)
This module asks about mosquito nets owned or used by the household.
Salt Iodization Module (SI)
This module includes a measure of the salt in the household, and asks where the salt was acquired.
Final Household Instructions (FH)
This module consists of instructions for the interviewer, including instructions about how to proceed
(either with a Woman’s Questionnaire or an Under 5 Questionnaire).
Woman's Questionnaire
In a household that has been selected for the survey, every woman between the ages of 15 and 49
will be administered the Woman's Questionnaire. A brief overview of the contents of each module in
the Woman’s Questionnaire follows.
Woman’s Information Panel (WM)
This module contains identifying information about both the household and the specific woman being
interviewed.
Marriage Module (MA)
This module is administered to all women between 15 and 49 years of age. It gathers information
about the woman’s marital status, and when the woman was first married to began living with a
partner. If a woman has never been married and has never been with a partner, the interviewers will
skip the next four modules and go directly to the Contraception Module (CP), otherwise, the interview
will continue with the Reproduction and Child Survival Module (RC).
Reproduction and Child Survival Module (RC)
This module asks questions related to how many children the woman has had, whether the children
are still living, and if so, whether they are living with the woman or elsewhere.
Live Birth History Table (BH)
This table is used to record details about each live birth the woman has had. Up to 20 births may be
recorded on this table.
Maternal and Newborn Health Module (MN)
This module gathers information about pregnancies the woman has had in the past two years. If the
woman has had no pregnancies in the two years preceding the interview, the interviewer will skip
directly to the Contraception Module (CP). For women who have been pregnant in the two years
preceding the interview, questions are asked related to the antenatal care they may have received,
the outcome of their pregnancy or pregnancies, and any problems that may have occurred during or
immediately following their last completed pregnancy.
Tetanus Toxoid Module (TT)
This module asks about anti-tetanus injections the woman may have received during her last
pregnancy.
Contraception Module (CP)

This module gathers information about the woman’s contraceptive knowledge. Additionally, for those
who have ever been married or in a partnership, information is gathered about the woman’s
contraceptive use.
HIV/AIDS Module (HA)
This module contains questions related to the woman’s HIV/AIDS knowledge.
Final Woman’s Questionnaire Instructions (FW)
This module consists of instructions for the interviewer, including instructions about how to proceed
(either with another Woman’s Questionnaire or an Under 5 Questionnaire).
Under 5 Questionnaire
In a household that has been selected for the survey, an Under 5 Questionnaire will be completed for
every child under the age of five. The mother or caretaker of the child will answer the questionnaire
for the child. A brief overview of the contents of each module in the Under 5 Questionnaire follows.
Under-Five Child Information Panel (UF)
This module contains identifying information about both the household and the specific child about
which information is being collected.
Birth Registration Module (BR)
This module asks simply whether the child has a birth certificate or not, and if not, requests the
reason for not having a birth certificate.
Vitamin a Module (VA)
This module gathers information about the child’s intake of Vitamin A supplements.
Care of Illness Module (CA)
This module contains questions on the child’s health, and what actions are taken if the child becomes
ill.
Malaria Module (ML)
This module focuses specifically on malaria. It gathers information about whether the child has been
sick with malaria in the past two weeks, and if so, whether any medicine was given to the child.
Excreta Disposal Module (EX)
This module is administered only if the child is less than 3 years old. A question about disposal of the
child’s stools is asked.
Breastfeeding Module (BF)
This module is administered only if the child is less than 2 years old. Information is gathered about
the child’s breastfeeding patterns.
Immunization Module (IM)
This module is most easily administered if there is an immunization card available for the child. If one
is available, the interviewer will record the information from the card. If a card is not available, the
interviewer will ask questions about the vaccinations that have been given to the child.
Anthropometry Module (AN)

This module includes height and weight measurements for each child, in addition to presence or
absence of edema..

Summary of indicators covered by SHHS:
Mortality indicators Maternal Health Indicators
Under-five mortality rate Skilled attendant at delivery
Infant mortality rate Institutional deliveries
Maternal mortality ratio Prevalence and content of antenatal care
Indicators on Marital Status Indicators on family planning
Polygamy Contraceptive prevalence
Young women aged 15-19 years currently
married or in union
Unmet need for family planning
Marriage before age of 15 Demand satisfied for family planning
Child health indicators Indicators on Immunization
Care-seeking behaviour for suspected
pneumonia
Immunization coverage for Tuberculosis, Polio,
diphtheria, pertussis and tetanus (DPT) and Measles
Antibiotic treatment of suspected
pneumonia
Neonatal tetanus protection
Timely initiation of breastfeeding Indicators on Nutritional Status
Adequately fed infants Iodized salt consumption
Use of oral rehydration therapy (ORT) Vitamin A supplementation (under-fives)
 Home management of diarrhea Vitamin A supplementation (post-partum mothers)
Source of supplies (insecticide-treated
mosquito nets, oral rehydration salts,
antibiotics and antimalarials for children)
Wasting prevalence
Low-birth weight infants
Underweight prevalence
Indicators on Child Rights Indirect Health Indictors
Child labour Adult literacy rate
Labourer students Pre-school attendance
Birth registration Net primary school attendance rate
Prevalence of female genital
mutilation/cutting (FGM/C)
Net secondary school attendance rate
Children reaching grade five
Approval for FGM/C Primary completion rate
Use of improved drinking water sources and Water
treatment
Use of improved sanitation facilities
Indicators on Malaria and HIV/AIDS
Comprehensive knowledge about HIV
prevention among young people
Household availability of insecticide-treated nets
(ITNs)
Knowledge of mother-to-child transmission
of HIV
Under-five sleeping under insecticide- treated nets
Counselling coverage for the prevention of
mother-to-child transmission of HIV
Under-five sleeping under mosquito nets
Antimalarial treatment (under- fives)

Implementation and implementation Modalities...............
2.1 Implementation Modalities and State Team Setting

2.2. Team Setting
1. As seen in the above diagram, the SMT is composed of three persons: the
statistical officer, the logistic and communication officer and the team leader, the
Federal Supervisor. The SMT members had arranged the team setting to be in the
CBS office in Nyala, before the arrival of the FSSM.
2. It is composed of two offices, each of 3x4 rooms and an additional store of 2x3
meters. All are of good lighting and proper ventilation.
3. There are the following functioning equipments:
i. A P4 computer, with full multimedia
ii. HP LaserJet 1320 Printer
iii. A Fax/Telephone Set (required maintenance twice in a month)
4. The team was further divided according to clear TOR, as follows:
i. The statistical officer was responsible for the technical work in terms of recording,
editing, revising, and reporting the questionnaires.
ii. The logistic and communication officer was responsible for the preparations of the
teams' needs utilities, food, water, readability of cars, and the communications to the
addressed locality stakeholders.
5. Almost each step done by any member has its format and checklist agreed upon
and followed by the team. The SMT stays daily from 9.00 am until 6.00 pm,
sometimes as late as 10.00 pm1
.
6. Although it was the first time this team works together, there was a real harmony
and smoothness in manipulating the constraints; this was a key factor in the
achievement of our work despite all the constraints SMT faced.
2.2 Advocacy
2.2.1. Advocacy started by the state members before the arrival of the Federal State
Survey Manager.
2.2.2. The levels of advocacy (the target audience) included:
i. The Under Secretary of the SMOH
ii. HE the State Minister of Health
iii. HE the Deputy Wali (Governor) of South Darfur State
iv. The representatives of NGOs attended the opening ceremony of the training
course.
v. The governor of the locality of Nyala
vi. The team leaders of the UN partner agencies, namely WFP, UNICEF, UNFPA,
WHO & other NGOs followed then.
vii. The governors of the localities and the local community leaders as needed prior to
the movement of each team to the given locality/village.
viii. The General Police Commander of the state.
1
Not a single day was made off, or holiday for the last 70 days

ix. The local community leaders.
2.2.3. The advocacy was an ongoing process all through the survey conduction.
There was a weekly update made for the U/S of SMOH, and all the NGOs working in
the field of health. This is done in the weekly health coordination meeting held in WHO
office in Nyala.
2.2.4. The update for H/E the Minster of Health was done almost every two weeks.
2.2.5. There were continuous regular visits to the UN partners almost twice a week,
especially to the NGOs that assigned a SHHS focal person.
2.2.6. The outcome of this advocacy policy will be detailed in the needs assessment
section of this report. The overall outcome is considered satisfactory.
2.2.7. The strengths of the advocacy policy were:
i. The clarity and unity of the message
ii. The multi-level approach
iii. The community component, in addition to the official authorities
iv. The continuity and the regularity of communications
v. Provision of the sense of ownership for each audience
2.2.8. The limitations of the advocacy policy were:
i. The communications between the Khartoum offices of the UN agencies were almost always
absent except for the WHO office. This led the SMT to start from the beginning explaining the
survey from A-Z.
ii. This caused the loss of precious time and led also to refusal of WFP office in Nyala to
provide any kind of real help to the survey, unless a "green light" comes from the WFP office in
Khartoum, which never happened till the end of the survey.
iii. There was no emphasis on the local community awareness preparations, e.g. the cars with
loud speakers moving in the streets of the selected village. This is justified by the fact that only
the political parties and the singers' concerts are announced this way; this would have been
misleading.
iv. In addition, the concurrent Polio campaign would have misled the people mixing our work
with that of the campaign using the same media.
2.3 Areas covered and substitutions:
There were 40 areas selected, most are rural all over the nine localities of the state. Selection
was population proportional; i.e. the number of clusters in each locality depends on the
population of that locality; this explains that there are nine clusters in Nyala locality, and only one
cluster in Adila, for instance.
In each cluster, all the households are listed, then 25 households are randomly selected. The
total number of covered household is 1000 (25 x 40). This is applicable to all the other states.
Taking the same number of households for all the states despite their widely variable population
densities was raised as a technical question and might be considered as limitation of the study.

SN Locality
Total No. of
Clusters
No. of
cluster
covered
No. of clusters
replaced
%
replacement
1 Nyala 9 6 3 33
2 Kass 3 2 1 33
3 Id Alfirsan 7 6 1 14.3
4 Tulus 2 2 0 0
5 Buram 7 2 5 71.4
6 De'ain 5 4 1 20
7 Rehaid alberdi 1 1 0 0
8 Adila 1 0 1 100
9 Sheriya 5 0 5 100
Total 40 26 14 35
The following table shows the villages that were substituted in each locality highlighted by
light yellow.
No. Locality Village/District Adm. Unit
Substitution
Adm. Unit Village/District
1 Nyala Wihda Hara Ula Nyala South
2 Nyala Aljabal Hara Ula Nyala South
3 Nyala Sikka hadid N&S Nyala South
4 Nyala Khartoum Bilail Nyala North
5 Nyala Kaira Nyala North Bilail Mosey
6 Nyala kankoli Aljabal Eastِ Bilail Galdi
7 Nyala Aglirai Bilail
8 Nyala Daira East Aljabal Bilail Domaya Almasjid
9 Nyala Daliaba south Abu Jabra
10 Kas Daldol Kas
11 Kas Karandi Kas
12 Kas Hillat nimi Kas
13 Adila Youm Abu Karinka Nyala North Amakasara
14 Idalfirsan Almodira Kobom Idalfirsan Um Dirso
15 Id Alfirsan Fokarin Idalfirsan
16 Id Alfirsan Um labasa Um labasa
17 Id Alfirsan Shakhara Katila
18 Id Alfirsan Dambloya Idalfirsan
19 Id Alfirsan Alsamza Idalfirsan
20 Id Alfirsan Almalam Idalfirsan

Substitution
Adm. Unit Village/District
21 Shereya Almarwa Bilail Seraif
22 Shereya Hillat umda abdalla Bilail Domaya alkoma
23 Shereya Um hawayim Bilail Domaya Al-um
24 Shereya Nitaiga alum Bilail Gad Alhabob
25 Shereya Jorof Nyala North Shadida
26 Tulus Alsadaga
27 Tulus Dimso wasat
28 Buram Alwalyim Buram
29 Buram Um marahik Buram Um Labbasa Tayba
30 Buram Tanzania Algoz Um Labbasa Al-Borie
31 Buram Abu hilal Buram Rehaid Al-Berdi October
32 Buram Aradaib Algoghana
33 Buram Sowaina Buram Rehaid Al-Berdi Sheikan
34 Buram Rahd albairid Buram Abu Ajora Sanya Dalaiba
35 Rehaid Albardi Hai alnojomi
36 De'ain Algobba
37 De'ain Abo sinaidra east
38 De'ain Lihlihaya
39 De'ain Abu matarig
40 De'ain Abu gabra Abu matarig Abu matarig B
The conditions related to the substitution are discussed in further details in the discussion
chapter.
2.4 Situation of needs and their fulfillment
The list of needs that the SMT required from partners included:
1. vehicles: cars and plane flights
2. communications: field radios
3. Technical assistance: maps, local calendars, substitutions, security assessments,
etc.
The needs that were made available are as follows:

Item No. Source/Donor Availability
and function
Remarks
Cars 3 SMOH Available,
secured
all were maintained more than
three times each due to their poor
conditions
1 UNFPA Nyala Office
paid for car
rental for 3
days 60.000
SD
We added another 80.000 SD for
the maintenance of SMOH car to
be with our teams for the rest of
the survey
1 WHO CANCELLED All our selected areas are no-go
areas with one UN car. Thus it is
useless, unless 2 other cars are
made available by other UN
agency(s)
Plane flights 8 UNICEF All secured by
UNICEF
UNICEF had to pay for 2 team
members who couldn't catch their
team, because of not having their
ID cards. They also managed a
misunderstanding that took place
in the airport.
Communications General
network
Very poorly &
hardly
available
The mobile and landlines phones
are very unstable and were off for
7 full days in the first month of
work. The NGOs that offered help
had no field offices in the selected
clusters.
Others
(stationary, logo
stickers)
UNFPA Available,
secured with a
cost of about
60.000 SD
UNFPA team leader in Nyala was
very committed, and helpful.
Technical
assistance
UNICEF,
WHO, NCA,
MSF-H & ARC
They are very helpful and very
interested in the methodology and
offered valuable advices about the
technical aspect of the work.
2.5 Supervisory visits
2.5.1. The supervisory visits of the SMT to the field were important for the data quality
control.
2.5.2. Although none was available because of the difficulty of finding a vehicle for any
supervisor, the statistical officer in the SMT managed two supervisory visits to the
teams in Rehaid Albirdi and Id Alfirsan areas. They had a very strong positive effect
on the morale of the teams.
2.5.3. It is important to mention that we have been kindly offered a ride for our
supervisors from NCA & ARC. Unfortunately the areas they offered were not the same
as ours.

2.5.4. The SMT had Mr. Abdalbari, the M&E officer from UNICEF, as the Federal
Supervisor who made a very fruitful visit. He helped us re-arranging some points, and
motivated the morale of the team and helped in resolving some pending points. He
also helped in formulating our assessment for the conduction of the survey by the
team in the field.

4. Discussion
4.1 Technical Limitations
Limitations in survey design and implementation are the rule, not the exception in field
epidemiology, mainly in complex emergencies. However, a balanced review of how these
limitations have affected the results is key to the interpretation of results and to the choice
of the most appropriate actions.
Several surveys on mortality and nutrition have been conducted, most estimating values
that were widely divergent. Much of this variation was due to the difficulties in estimating
mortality among transient populations and insecure conditions. Denominators are
particularly difficult to establish among rapidly moving populations.
This being said, obtaining data on death, disease or malnutrition rates in conflict
situations is far from simple. First, death rates will differ according to who gets surveyed.
This clearly applies to the different population groups in Darfur. Internally displaced
populations live in appalling conditions and typically have death rates far above any
emergency threshold. Residents who have not had to move, on the other hand, are
usually better off. Moreover, the rate at which refugees die depends on their condition
when they arrive in a given camp. As a result, using rates from a specific group (the most
disadvantaged) to extrapolate deaths for the whole population can seriously distort the
real picture.
Second, estimates will differ according to the timing of surveys. There are months in the
year where deaths are frequent because of temporary escalation of violence, seasonal
disease outbreaks or breakdowns in food supply. If data is collected right after or during
one of these periods, the estimated death toll will be high. Applying this death rate to the
entire region for the entire year will be grossly misleading.
Third, estimations of mortality have to be considered in the light of the counter-factual,
i.e. how many people would have died, if the conflict had not occurred? It is very difficult
to estimate the excess deaths without knowing the baseline mortality, which is the
number of those who would have died anyway without the conflict.
Fourth, stereotypes of conflict-related mortality frequently dominate the debate and
distort clear decision making processes. Outright violence is rarely the main cause
among populations affected by conflict. The IRC mortality study in eastern Democratic
Republic of Congo shows that deaths due to violence represent less than 20% of all
causes (IRC, 2001). Data suggest, however, that there is a correlation between violence
and infectious diseases and malnutrition, which suggests that "people in those areas with
the most violence suffer the most displacement" and therefore have a higher probability
of dying from the latter causes.
The recall period of this survey, more than 6 months, was longer than previous WHO-
EPIET survey and other surveys. In general, the longer the study, the more susceptible to
biases it is, such under-reporting of deaths further back in the past; this could in theory
limit the validity of the comparison with the previous survey. To limit recall bias, a local
calendar of events was used to assist in the definition of precise month of death or birth
as well.

In order to collect such a wealth of information in a short period, the survey was
particularly labour intensive, with some 50 people directly involved in the field work. An
effort was made to standardize methods and techniques through an intensive training
and a strong supervision of interviewers, so as to improve reliability of findings; however,
some residual variation cannot be excluded. Additionally, our internal inspection of data
did not reveal any apparent patterns in questionnaire responses (measurement bias)
according either to interviewer team or surveyed population type, a proxy affirmation that
there were no major differences in the data collection process among interviewers and/or
surveyed.
An information bias, such as providing inaccurate death data or information on the size of
the household or on the availability of food or non-food aid, so as to justify more aid,
cannot be completely ruled out. This bias would probably be towards under-reporting
mortality. However, at the beginning of the interview, the respondents were informed that
all the information provided was confidential and that the study was not part of a
registration process for the distribution of aid.
The Darfur crisis has had political connotations from the beginning, and manipulation of
information, like mortality, has been instrumental to opposite political ends. The possibility
of political biases affecting the survey, that is both under and over-reporting mortality for
political purposes in order to minimize or conversely exaggerate the effects of the crisis
has been carefully considered. The following measures were taken to reduce the
influence of this bias: a close supervision of interviewers by a number of national,
politically neutral supervisors and coordinators, discussions with other UN agencies
experts for the validation of preliminary results and internal comparisons of findings.
4.2 Accessibility and Security Limitations:
The literature about previous fieldwork in Darfur, in general and particularly South Darfur
documents very well the major problems of feasibility and accessibility issues. Accessibility
and security were indeed the biggest limitation that faced our work, and should be seriously
taken when manipulating the gathered data. This includes all the stages from data entry to
analysis to the final report.
Other fully supported and well-budgeted surveys like the Crude Mortality Survey, conducted
last year faced similar conditions and they could hardly cover as low as 70% of the areas. If
this is the case with the UN agencies, which have much better chances to access areas that
are not accessible by GOS staff, then we should be expecting even less coverage in terms of
the constraints the work faced at different levels.
For statistical purposes and after deep technical and financial discussions, the steering
committee came out with the conclusion that the clusters from each state should complete 40
clusters to be statistically comparable with the same weight to other states of the country.
More specifically, this survey was conducted in extremely difficult circumstances, within an
uncertain and fragile security situation, need for frequent cross-line movements and
enormous logistic challenges to transport simultaneously an average of 4 teams, each of 6
interviewers and a driver for the state to scattered locations.
The Locality of Sheriya was a big question from the beginning of the survey. It is known that
it is not accessible not only for GOS staff, but also for most of the NGOs staff. UNICEF had
mediated long hard negotiations with the rebel forces, hoping that either one of teams find an

access, or to achieve the alterative plan to train people from inside Sheriya to conduct the
survey there. This solution, in case the negotiations succeeded, would have raised very
important questions about the extra-time and budget and above all the quality of the collected
data; knowing that it is even hard to find people who are not illiterate in such a place deprived
from most the basic needs of shelter, food and security.
This had put an additional ethical burden about those people who were deprived from being
studied because they are in inaccessible and insecure areas.
Worse situation was in Buram, where our team could hardly finish two clusters before the
security situation got inflamed. Their personal security was in hazard and their exposure to
direct physical hazard was very possible1
. Fortunately, this did not happen, but this indeed
increased the areas to be substituted to complete the 40 clusters in the state.
Despite all the technical and ethical considerations; substitutions seemed to be the most
feasible solution.
Nevertheless, substitution of any inaccessible village as follows:
o The nearest accessible village; or
o If more than one village that seem equidistant, one is selected randomly from them.
1
There is an official document from the National Security and Intelligence Agency that explains the situation. This
document is classified and will not be attached to the report.

5. Conclusions and Recommendations
This survey was carried out before the rainy season, when the transmission of malaria
peaks, food and non-food distribution becomes more difficult and the hunger season starts.
As discussed in previous sections of the report, nothing can be said on mortality and other
indicators in areas that could not be included in the survey, because of lack of accessibility,
particularly in the areas of Sheriya and Buram.
The data generated by the study, and in particular mortality data, need to be analysed
together with those produced by the early warning system, with the objective of better
interpreting the survey’s results and validating the coverage and quality of the surveillance
system.
Prospective mortality surveillance is also being advocated, since it enables real-time
monitoring of the crisis and, therefore, a prompter response. On the other hand, the
requirements for sustaining quality surveillance through supervision are high. Additionally,
population movements need to be minimal for a surveillance system to produce good
mortality data. Thirdly, surveillance systems have a limited coverage, usually limited to
camps, and cannot inform about vast areas, as surveys can. In conclusion, as a recent
review points out (Checchi and Roberts, 2005), surveys and surveillance should not be seen
as mutually exclusive, but rather as complementary.
In terms of implementation of the survey at the state level, the overall evaluation is
satisfactory. The SMT was homogenous and well-motivated. It performed in harmony and
consistency. The estimated time for achieving the given clusters was indeed very unrealistic
for South Darfur State conditions.
Better knowledge and more recent assessments of the situations in situ should have been
available before the sampling, or the estimation of time and budget is finally done. The
fragility of the security situation, specially being in coincidence with the peace negotiations,
would indeed make this clear assessment hard to obtain.
The budget lines were not fulfilling all the real needs; this is partially explained by the fact that
planning of the survey at all its levels was at a central federal level. The estimations
depended on the outlines decided by the partners, who would prefer to come with best
results at the least possible cost. In the same aspect, the commitment of the partners in the
field work was variable and far from clarity.
Although this survey is a benefit for everyone, no one seemed to have similar enthusiasm to
get committed. This does not undermine the great help we had from many agencies (please
refer to the acknowledgment section).
Mini- and wide range surveys should be encouraged and conducted by all the NGOs working
in South Darfur; this should be an integral part of any intervention effort.
Finally, as soon as the final report is ready, the findings of this survey need to be circulated
widely among humanitarian actors and donors in order to work for solving the ongoing
humanitarian crises in Darfur, increase humanitarian access and to maintain and enhance
funding for protection and promotion of sustainable health as the health systems in Darfur
recovers from the crises.

References.....................................................................................
1. Mortality survey among Internally Displaced Persons and other affected
populations in Greater Darfur, Sudan. World Health Organization and
Federal Ministry of Health, Sudan September 2005.
2. CDC and WFP: Emergency nutrition assessment of crisis affected
populations, Darfur Region, Sudan, 2004
3. Centre for Research and Epidemiology of Disasters: Report on mortality and
nutrition in Darfur, Sudan, March 2005
4. Checchi F: A Survey of Internally displaced persons in El Geneina, Western
Darfur, Epicentre Report, July 2004
5. F.Checchi, L.Roberts: Interpreting and using mortality data in humanitarian
emergencies.
6. Overseas Development Institute; Network Paper No.52, 2005
7. Guha-Sapir, D., Degomme, O.: Darfur: Counting the Deaths. Mortality
Estimates from Multiple Survey Data. Research report, WHO Collaborating
Centre for Research on Epidemiology of Disasters (CRED), Brussels, May
2005
8. Hofmann CA, Roberts L, Shoham J et al: Measuring the impact of
humanitarian aid. A review of current practice; Overseas Development
Institute, Humanitarian Policy Group Report 17, 2004, accessible at:
http://www.odi.org.uk/hpg/papers/HPGReport17.pdf
9. International Rescue Committee: DRC mortality survey, 2001
10.Médecins Sans Frontières. Refugee Health; an approach to emergency
situations, Médecins Sans Frontières. Paris 1995
11.Noji E. The Public Health Consequences of Disasters. New York: Oxford
University Press, 1997
12.Office for Coordination of Humanitarian Affairs: Inter-agency real-time
evaluation of the humanitarian response to the Darfur crisis, July 2005
13.Office of the UN Resident and Humanitarian Coordinator for the Sudan, July
2005 (1) Darfur Humanitarian Profile No.14; January - April 2005 review,
accessible at: http://unsudanig.org/emergencies/darfur/profile/index.jsp
14.Office of the UN Resident and Humanitarian Coordinator for the Sudan, July
2005 (2): Darfur Humanitarian Profile No 16, July 2005 (2), accessible at:
http://unsudanig.org/emergencies/darfur/profile/index.jsp
15.Office of the UN Resident and Humanitarian Coordinator for the Sudan,
Funding Overview for the Darfur Crisis, February 2005
16.Singh JA: Genocide: burden of proof and inaction is costing lives in Sudan;
The Lancet, vol 364: 230-1, 2004
17.UNICEF: State of the World's Children 2005
18.WHO: Immunization coverage cluster survey reference manual, 2004

Annexes:
MAPS OF DARFUR

Note: To avoid over sizing of the file, please refer to the following link to get
a copy of the relevant topic:
www.SHHS.i8.com
In this website the following documents in both Arabic and English:
Woman Questionnaire
Under5 Questionnaire
Community Food Security Questionnaire
Community Questionnaire
Selected clusters

Sudan Household health Survey (SHSS) South Darfur technical report 2006

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