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Job Title: International Consultants | National accreditation system
Supervisor: Director General of Quality Directorate
No. of Post: 2
Duty Station: Khartoum
Duration: 28 days
Closing Date: 19 Jan 2017


Job Title:  International Consultants to establish a national accreditation system for healthcare facilities in order to improve the quality of health care services ( Budget line: 318)

Supervisor:  Director General of Quality Directorate

Duty Station:  Khartoum

No of consultants: 2

Duration of assignment: 28 days

Closing Date: 10 days after the announcement


The Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund funds for HSS based on the World Health Organization (WHO) health systems framework that identifies ‘six building blocks’: governance, financing, information, human resources, medicines and technology, and service delivery.  In the context of the Global Fund's mandate, HSS refers to activities and initiatives that improve the underlying health systems of countries in any of the ‘six building blocks ‘identified above. Inadequate health systems are one of the main obstacles to scaling-up interventions to secure better health outcomes for HIV, tuberculosis, and malaria.

 Improvement in the quality of hospital care is a fundamental aspect of health system strengthening that is directly linked to the service delivery dimension of the World Health Organization (WHO) building blocks of a health system.  While the monitoring of hospital performance is a key ingredient to such improvement.

Quality improvement is considered a permanent obligation and a priority for health service development. Following the Declaration of the International Conference on Primary Health Care, held in Alma-Ata, USSR (now Almaty, in 1978 (3), World Health Organization  invited its Member States to act individually in formulating national policies, strategies and plans of action for attaining the goal of Health for all by the year 2000 and collectively in formulating regional and global strategies.

Regional Committee resolution passed in   required Member States to install a national quality programme, supported by WHO’s for the continuous improvement of the quality of care provided. Member States were urged to establish a national quality of care programme designed as one of the main components of health sector reforms, given its impact on the outcome expected of other programme.

Promotion of equitable coverage and accessibility of quality integrated primary health care through provision of quality secondary and tertiary care services are emphasized under ministry of health priority goal of Sudan. Sudan health system is based on the district health system approach, which emphasizes the principles of primary health care (PHC). In addition Hospital is one of an integral part of health system for continuation of cares. Nevertheless, lack of access to high quality primary health care services is evident in Sudan particularly in rural and peripheral areas due to lack of financial resources and managerial capacities.

Access to high quality PHC services is one of the major problems of Sudan’s health system. Among others, below the standard health care package and delivery practices are found to affect quality of care AS it was stated in the policy option, proper access to high quality PHC services is promoted by strengthening the quality of primary healthcare through establishing and implementation of health care accreditation system.

Accreditation is a formal process by which a recognized body assesses and recognizes that a health care organization meets applicable pre-determined and published standards. Accreditation standards are usually regarded as optimal and achievable, and are designed to encourage continuous improvement efforts within accredited organizations. An accreditation decision about a specific health care organization is made following a periodic on-site evaluation by a team of peer reviewers, typically conducted every two to three years. Accreditation is often a voluntary process in which organizations choose to participate, rather than one required by law and regulation.

Sudan health facility accreditation system has been established by Quality Directorate – Federal Ministry of Health in consultation with many stakeholders. The ministry demonstrated commitment for quality improvements and Important steps has been taken under this directorate in this regard Conducted an initial surveys for accreditation (using the Arab tool) in five states hospitals; Drafted the national healthcare accreditation council Law; Develop and endorsement of hospitals and PHC accreditation standards; Conduct training and study tour on basics of accreditation system in collaboration of HCAC (Jordan).

Establishing and implementation of national accreditation system will help to ensure health care facilities including hospitals (private or public) provided   evidence based quality health care for the nation .However accreditation is not an end process, there has t be continuous monitoring of performances against the standards and sustain the high quality.

The Quality Directorate unit of SMOH, identified under project implementing unit, manage the implementation of quality health care services  need to hire a consultant in order to support the Directorate General of Quality, Development and Accreditation (DGQDA) in hospitals accreditation processes. The costs of the assignment will be covered by grant from the Global fund HSS.


Objective of the consultancy work:

 The purpose of the consultancy service is to assist The Federal Ministry in fulfilling its responsibilities to ensure the quality of patient-centered care and equitable access to health services by conducting survey for as preliminary hospital accreditation process using standardized quality assessment method guidelines and policies established by national and international body.


  • To review relevant literature including: existing quality norms, policy guidelines, standards and identified nationally or international health accreditation systems.
  • Conduct baseline assessment for accreditation for the selected hospitals (5 hospitals) using Sudanese hospitals accreditation standards.
  • Analyzing the strengths and weaknesses as well as the existing opportunities and impending threats for developing and implementing the accreditation system in those hospitals;
  • Identifying gaps, options appraisal and priorities setting for implementing accreditation system;
  • Conduct capacity building and training on performance management of the health care delivery and reporting.
  • To conduct a training needs assessment on capacity and preparedness for accreditation at governance and implementation levels;
  • Develop priority interventions to fill the identified gaps (improvement plans development)
  • To discuss the requirements for initiation and completion of the accreditation process. 
  • To conduct training on capacity building for surveyor   and award them a certified certifications

Scope of the work:

 As major part of their accreditation process is the consultant / Surveyors conduct unannounced hospital inspection. Reviews documents in all or selected functional area of health care delivery from admission and assessment to patient rights—and involve an intensive process of reviewing documents, medical records and conducting site tours, observations while serviced is provided and observe the structure and functioning of the system, and conduct staff and patient interviews .The surveyors also compile and analyze the collected data on performance indicators and present the result on appropriate format.



  • Inception report outlining the task to be undertaken and different methodology including time table.
  • Final survey of tools.
  • Final baseline assessment report.
  • Training needs assessment on capacity and preparedness document.
  • Improvement plans for the assessed hospitals.
  • Report on The numbers of the surveyors awarded certified certifications from HCAC documented.
  • Final recommendation report for accreditation.
  • Final report of the work and reference documents.

Qualifications of the International /national Consultant


  • Master's degree or equivalent in health care management, medicine, Public health, quality of care or other related disciplines.


  • Five or more years of experience in health care accreditation, quality assurance at national or international level.
  • Good understanding of international and national health care standards and guidelines.
  • Specific experience of accreditation and quality assurance with expertise in developing standards, quality improvement tools and programmers as well as research.
  • Proven writing skills in preparing similar documents in a consultancy assignment or regular job.
  • The applicants shall specifically demonstrate in their proposal past experience working successfully in a team.

Language Proficiency

  • Proficiency in English and knowledge of Arabic is an advantage (both spoken and written).


  • Demonstrated initiative and perseverance; self-starter, and comfortable in a multi-cultural team setting; personal sensitivity and commitment to the values of the United Nations; results driven, ability to work under pressure and to meet strict deadlines. The applicants shall specifically demonstrate in their proposal past experience working successfully in a team.



Institutional Arrangement

The consultants will work under the overall supervision of the head of The Quality Directorate unit of SMOH . For functional matters, the consultants will be guided by the Director General of International Health and the Senior Program Advisor at the PMU.

Duration of the Consultancy

It is anticipated that the assignment will be completed within a total of twenty eight days from the date of the signing of the contract. All work must be completed by the date which will be decided on signing of the contract between the consultant and the head of the health information unit.

How to apply:

Interested applicants should submit their CVs along with brief work plan to the DG of Quality on this E-mail:reemhealth@gmail.com