{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,18]],"date-time":"2026-08-18T18:25:12Z","timestamp":1787077512198,"version":"build-2736575974"},"reference-count":42,"publisher":"Public Library of Science (PLoS)","issue":"8","license":[{"start":{"date-parts":[[2026,8,18]],"date-time":"2026-08-18T00:00:00Z","timestamp":1787011200000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100007436","name":"Familjen Erling-Perssons Stiftelse","doi-asserted-by":"publisher","award":["N\/A"],"award-info":[{"award-number":["N\/A"]}],"id":[{"id":"10.13039\/100007436","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["www.plosglobalpublichealth.org"],"crossmark-restriction":false},"short-container-title":["PLOS Glob Public Health"],"abstract":"<jats:p>While the emphasis on strengthening and utilising a unified national system has gained momentum in discussions among health partners throughout the world, there are evident discrepancies between commitments and practice. Sudan presents an interesting case where the last decade has witnessed major political changes that have influenced health sector partnerships. This study investigates the shifts in attitudes and practices of Sudan\u2019s health sector partners towards strengthening and utilising the national health system, specifically focusing on the components of financial management, procurement and supply, and health information. Utilising a qualitative case study design, data were collected through semi-structured interviews with key stakeholders from various humanitarian and developmental partners during two rounds (2015 and 2021\/22). The interviews were analysed thematically, and situational analysis was applied with the partners\u2019 stances displayed on positional maps. The findings revealed a shift from initial resistance to and prevention of system strengthening and utilisation to a more collaborative approach towards the system utilisation, influenced by political changes, and the need to adopt resilient approaches to respond to the volatile emergency context. Meanwhile, over time humanitarian partners have persisted to utilise their own systems because they have control over these systems or believe their systems function better. Moreovere, some respondents claimed that they are not mandated to support a unified system. Tension persists between utilising the system as prerequisite to strengthen it or ensuring the system is strengthened before using it. The study highlights the critical need for continuous monitoring and commitment to utilising the national system by all to ensure sustainability and enable timely improvement, especially in fragile contexts like Sudan. Flexible arrangements and guidance to encourage humanitarian partners to commit to abolishing parallel systems are crucial.<\/jats:p>","DOI":"10.1371\/journal.pgph.0007039","type":"journal-article","created":{"date-parts":[[2026,8,18]],"date-time":"2026-08-18T17:33:01Z","timestamp":1787074381000},"page":"e0007039","update-policy":"https:\/\/doi.org\/10.1371\/journal.pgph.corrections_policy","source":"Crossref","is-referenced-by-count":0,"title":["Attitudes and practices of Sudan\u2019s health sector partners towards strengthening and utilising the national health system components (2015\u20132022)"],"prefix":"10.1371","volume":"6","author":[{"ORCID":"https:\/\/orcid.org\/0009-0003-7488-4777","authenticated-orcid":true,"given":"Huzeifa","family":"Aweesha","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anni-Maria","family":"Pulkki-Br\u00e4nnstr\u00f6m","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anna-Karin","family":"Hurtig","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Miguel San","family":"Sebastian","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2026,8,18]]},"reference":[{"issue":"12","key":"pgph.0007039.ref001","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pmed.1000385","article-title":"Toward a consensus on guiding principles for health systems strengthening","volume":"7","author":"RC Swanson","year":"2010","journal-title":"PLoS Med"},{"issue":"9437","key":"pgph.0007039.ref002","doi-asserted-by":"crossref","first-page":"900","DOI":"10.1016\/S0140-6736(04)16987-0","article-title":"Overcoming health-systems constraints to achieve the Millennium Development Goals","volume":"364","author":"P Travis","year":"2004","journal-title":"Lancet"},{"issue":"9681","key":"pgph.0007039.ref003","doi-asserted-by":"crossref","first-page":"2137","DOI":"10.1016\/S0140-6736(09)60919-3","article-title":"An assessment of interactions between global health initiatives and country health systems","volume":"373","year":"2009","journal-title":"The Lancet"},{"key":"pgph.0007039.ref004","unstructured":"Organization for Economic Co-operation and Development. Development Co-operation Report 2015: Making Partnerships Effective Coalitions for Action. Paris: OECD Publishing. 2015."},{"key":"pgph.0007039.ref005","volume-title":"Health Systems Strengthening Glossary","author":"World Health Organization","year":"2011"},{"key":"pgph.0007039.ref006","doi-asserted-by":"crossref","first-page":"5","DOI":"10.1186\/s12992-015-0090-3","article-title":"Strengthening health systems in low-income countries by enhancing organizational capacities and improving institutions","volume":"11","author":"RC Swanson","year":"2015","journal-title":"Global Health"},{"issue":"1","key":"pgph.0007039.ref007","doi-asserted-by":"crossref","first-page":"22","DOI":"10.1186\/1478-4505-8-22","article-title":"What can global health institutions do to help strengthen health systems in low income countries?","volume":"8","author":"D Balabanova","year":"2010","journal-title":"Health research policy and systems"},{"issue":"9773","key":"pgph.0007039.ref008","doi-asserted-by":"crossref","first-page":"1222","DOI":"10.1016\/S0140-6736(10)60679-4","article-title":"Health-systems strengthening: current and future activities","volume":"377","author":"J Sundewall","year":"2011","journal-title":"Lancet"},{"key":"pgph.0007039.ref009","unstructured":"UHC2030. Seven behaviours for development partners to change. https:\/\/www.uhc2030.org\/fileadmin\/uploads\/ihp\/Seven_behaviours\/UHC2030_seven_behaviours_products\/UHC2030_postcard_7_behaviours_V2.pdf. 2013. Accessed 2023 October 1."},{"key":"pgph.0007039.ref010","doi-asserted-by":"crossref","first-page":"13","DOI":"10.1186\/1744-8603-8-13","article-title":"The International Health Partnership Plus: rhetoric or real change? Results of a self-reported survey in the context of the 4th High Level Forum on Aid Effectiveness in Busan","volume":"8","author":"T Shorten","year":"2012","journal-title":"Global Health"},{"issue":"9590","key":"pgph.0007039.ref011","doi-asserted-by":"crossref","first-page":"803","DOI":"10.1016\/S0140-6736(07)61386-5","article-title":"The international health partnership","volume":"370","author":"D Alexander","year":"2007","journal-title":"Lancet"},{"key":"pgph.0007039.ref012","unstructured":"World Health Organization. Health systems governance for universal health coverage action plan. In. Department of health systems governance and financing; 2014."},{"issue":"6","key":"pgph.0007039.ref013","doi-asserted-by":"crossref","first-page":"333","DOI":"10.1080\/10803920.2013.855568","article-title":"Sudan\u2013south sudan: the unfinished tasks","volume":"35","author":"PN Lyman","year":"2013","journal-title":"American Foreign Policy Interests"},{"key":"pgph.0007039.ref014","unstructured":"Republic of Sudan Federal Ministry of Health, Development Partners, CSO, Implementation Partners. Sudan health compact. 2014. https:\/\/www.uhc2030.org\/fileadmin\/uploads\/ihp\/Documents\/Country_Pages\/Sudan\/SUDAN_HEALTH_COMPACT_September_2014_version.pdf"},{"key":"pgph.0007039.ref015","unstructured":"Inter-Agency Standing Committee. Exploring peace within the humanitarian-development-peace nexus (HDPN). IASC; 2020. https:\/\/interagencystandingcommittee.org\/sites\/default\/files\/migrated\/2020-10\/Issue%20paper%20-%20Exploring%20peace%20within%20the%20Humanitarian-Development-Peace%20Nexus%20%28HDPN%29.pdf"},{"key":"pgph.0007039.ref016","author":"D Schreiber","year":"2023"},{"key":"pgph.0007039.ref017","unstructured":"Republic of Sudan Federal Ministry of Health, Development Partners, Humanitarian Partners. Humanitarian Development and Peace Nexus Roadmap Plan. 2017."},{"issue":"4","key":"pgph.0007039.ref018","doi-asserted-by":"crossref","first-page":"567","DOI":"10.18502\/sjms.v16i4.9959","article-title":"Saving the fundaments: impact of a military coup on the sudan health system","volume":"16","author":"AK Osman","year":"2021","journal-title":"SJMS"},{"issue":"2","key":"pgph.0007039.ref019","doi-asserted-by":"crossref","DOI":"10.1111\/dpr.12757","article-title":"Sudan\u2019s health sector partnership: From confined progression to openness and hope to uncertain demise","volume":"42","author":"H Aweesha","year":"2024","journal-title":"Development Policy Review"},{"issue":"1","key":"pgph.0007039.ref020","article-title":"Public health consequences of armed conflict in Sudan in the face of global donor fatigue","volume":"3","author":"MK Musa","year":"2024","journal-title":"Public Health Chall"},{"issue":"4","key":"pgph.0007039.ref021","article-title":"Impact of the 2023 armed conflict on Sudan\u2019s healthcare system","volume":"2","author":"A Khogali","year":"2023","journal-title":"Public Health Chall"},{"key":"pgph.0007039.ref022","unstructured":"Republic of Sudan Federal Ministry of Health. 2016 and 2017 Joint Annual Review Report. 2017. https:\/\/extranet.who.int\/countryplanningcycles\/sites\/default\/files\/country_docs\/Sudan\/final_sudan_jar_report_november_2017.pdf"},{"key":"pgph.0007039.ref023","unstructured":"World Health Organization, Regional Office for the Eastern Mediterranean. Country Cooperation Strategy for WHO and Sudan 2022\u20132025. World Health Organization Regional Office for the Eastern Mediterranean; 2022 [cited 2025 Feb 2]. https:\/\/www.who.int\/publications\/i\/item\/9789290229698"},{"key":"pgph.0007039.ref024","unstructured":"Republic of Sudan Federal Ministry of Health. Sudan Health Account 2015. 2015. http:\/\/sho.gov.sd\/controller\/knowledge_hub.php?mid=110&sm_id=132&lid=1"},{"key":"pgph.0007039.ref025","unstructured":"Republic of Sudan Federal Ministry of Health. Sudan Health Sector Joint Financial Management Assessment Report 2016. 2016. https:\/\/www.uhc2030.org\/fileadmin\/uploads\/ihp\/Documents\/Key_Issues\/Financial_Management\/Sudan_Health_Sector_JFMA_Report.pdf"},{"key":"pgph.0007039.ref026","unstructured":"National Medical Supplies Fund. [cited 2026 Mar 2]. https:\/\/nmsf.gov.sd\/"},{"key":"pgph.0007039.ref027","unstructured":"Republic of Sudan Federal Ministry of Health. National Health Sector Recovery and Reform Strategic Plan 2022-2024. 2022."},{"key":"pgph.0007039.ref028","unstructured":"Republic of Sudan Federal Ministry of Health, World Health Organization. Assessment of Sudan\u2019s health information system 2020. 2022 [cited 2025 Oct 6]. https:\/\/iris.who.int\/items\/9d8dbe60-db7b-4e5a-98ba-a7b6cbdce39f"},{"issue":"9","key":"pgph.0007039.ref029","doi-asserted-by":"crossref","first-page":"1245","DOI":"10.1097\/ACM.0000000000000388","article-title":"Standards for reporting qualitative research: a synthesis of recommendations","volume":"89","author":"BC O\u2019Brien","year":"2014","journal-title":"Acad Med"},{"key":"pgph.0007039.ref030","doi-asserted-by":"crossref","DOI":"10.4135\/9781412985833","volume-title":"Situational analysis: grounded theory after the postmodern turn","author":"A Clarke","year":"2005"},{"key":"pgph.0007039.ref031","volume-title":"Situational analysis in practice: mapping research with grounded theory","author":"A Clarke","year":"2015"},{"key":"pgph.0007039.ref032","volume-title":"Qualitative methodology for international public health","author":"L Dahlgren","year":"2019","edition":"3"},{"key":"pgph.0007039.ref033","unstructured":"Health Data collaborative, UNICEF. Country case studies on health information system strengthening. 2022. https:\/\/data.unicef.org\/resources\/country-case-studies-on-health-information-system-strengthening\/"},{"issue":"1","key":"pgph.0007039.ref034","doi-asserted-by":"crossref","first-page":"25","DOI":"10.1186\/s13031-021-00355-8","article-title":"Healthcare governance during humanitarian responses: a survey of current practice among international humanitarian actors","volume":"15","author":"P Jarrett","year":"2021","journal-title":"Confl Health"},{"key":"pgph.0007039.ref035","doi-asserted-by":"crossref","first-page":"242","DOI":"10.4103\/jehp.jehp_1312_20","article-title":"Collaboration between the government and nongovernmental organizations in providing health-care services: A systematic review of challenges","volume":"10","author":"M Rajabi","year":"2021","journal-title":"J Educ Health Promot"},{"issue":"4","key":"pgph.0007039.ref036","doi-asserted-by":"crossref","first-page":"639","DOI":"10.1111\/j.1467-7717.2011.01235.x","article-title":"Rebuilding and strengthening health systems and providing basic health services in fragile states","volume":"35","author":"W Newbrander","year":"2011","journal-title":"Disasters"},{"issue":"1","key":"pgph.0007039.ref037","doi-asserted-by":"crossref","DOI":"10.4102\/phcfm.v11i1.1945","article-title":"Calling non-governmental organisations to strengthen primary health care: Lessons following Alma-Ata","volume":"11","author":"M Landes","year":"2019","journal-title":"Afr J Prim Health Care Fam Med"},{"issue":"5","key":"pgph.0007039.ref038","first-page":"561","article-title":"Collaboration between Government and Non-Governmental Organizations (NGOs) in Delivering Curative Health Services in North Darfur State, Sudan- a National Report","volume":"43","author":"A Yagub","year":"2014","journal-title":"Iran J Public Health"},{"key":"pgph.0007039.ref039","doi-asserted-by":"crossref","first-page":"1579825","DOI":"10.3389\/fpubh.2025.1579825","article-title":"Humanitarian-development nexus approach to health systems strengthening in Sudan-a policy analysis","volume":"13","author":"HJI Aweesha","year":"2025","journal-title":"Front Public Health"},{"key":"pgph.0007039.ref040","article-title":"International humanitarian NGOS and state relations politics, principles and identity","author":"AJ Cunningham","year":"2018","journal-title":"In. Routledge"},{"issue":"12","key":"pgph.0007039.ref041","doi-asserted-by":"crossref","first-page":"2134","DOI":"10.2105\/AJPH.2007.125989","article-title":"Strengthening health systems in poor countries: a code of conduct for nongovernmental organizations","volume":"98","author":"J Pfeiffer","year":"2008","journal-title":"Am J Public Health"},{"issue":"2","key":"pgph.0007039.ref042","doi-asserted-by":"crossref","first-page":"158","DOI":"10.1093\/jrs\/fej019","article-title":"Protracted refugee situations: parallel health systems and planning for the integration of services","volume":"19","author":"EA Rowley","year":"2006","journal-title":"Journal of Refugee Studies"}],"container-title":["PLOS Global Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pgph.0007039","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,18]],"date-time":"2026-08-18T17:33:09Z","timestamp":1787074389000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pgph.0007039"}},"subtitle":[],"editor":[{"given":"Baldeep Kaur","family":"Dhaliwal","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2026,8,18]]},"references-count":42,"journal-issue":{"issue":"8","published-online":{"date-parts":[[2026,8,18]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pgph.0007039","relation":{},"ISSN":["2767-3375"],"issn-type":[{"value":"2767-3375","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,18]]}}}