Co-ordination between Federal, State and District Levels in Managing Health Systems and Policy Implementation in North Darfur State
6.2 Factors affecting health system management and policy implementation at federal, state and district level in North Darfur State
6.2.2 Conflict
The conflict in North Darfur State has resulted in massive population displacement and widespread insecurity. This has consequently led to the further deterioration of the already undeveloped health system and infrastructure in the State (WHO, 2007a:64). The fragile health service system in Darfur was unprepared for the large influx of people requiring health care and the need for health services infrastructure became obvious, as only primary health care facilities were established in IDP camps and in some small towns. The State
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and local rural hospitals in Darfur were unable to sustain their programmes to provide free treatment to IDP camps and the conflict-affected people (WHO, 2007b:4).
In this regard, 89% of interviewees at federal and State level, and 95% at district level disclosed that the conflict weakened the infrastructure of health services in North Darfur State. Most of them also indicated that this caused the marginalization of the Darfur region from national government, together with the civil war that started in the region in the 1980s and ended in serious conflict between rebel groups and government forces in 2003.
This is confirms the FMoH Report (2007a:15), and the SMoH Survey Report (2010), which both stated that the conflict in North Darfur State has either destroyed much of health infrastructure or left it in need of maintenance and repair.
There have been reports of destruction of rural hospitals and clinics, increased absence of health care providers at these health facilities, blockades of essential drugs and other health commodities into certain health facilities, and difficulties in conducting supervision and monitoring visits by State health officers at district level (State Ministry of Health Survey Report, 2010). These factors have all impacted health policy implementation in the State.
This was confirmed by 95% of interviewees at all levels of government. 89% of interviewees at State level and all interviewees at district level disclosed that health policy implementation has failed completely due to conflict.
According to an interviewee (1-3, 11 January 2011, El Fasher) in the State Ministry of Health:
The conflict which exploded in North Darfur State has affected health policy implementation. This is because health policy is designed at federal level and needs to be monitored and implemented at district level. We don‟t have enough funds or enough qualified administration health staff to send them to the districts to evaluate the situation there and even if we send teams from the State level, they cannot reach the health centres and basic health units at district level, due to the insecurity.
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Brinkerhoff (2008: 6), has pointed out that sustainable health service delivery capacity, and efficient management systems and policy, along with effective policy making and health governance, are necessary for conflict-affected states to establish sustainable development of their health sectors.
According to another interviewee (2-8, 05 January 2011, El Fasher) working in the State Ministry of Health:
The conflict in North Darfur State affected every aspect of the health service delivery system in the State, such as limiting the human, material and financial resources for the implementation of health services policy. In the long-term the government should take the responsibility to improve and reform its health system and policy, so as to provide quality free medical treatment to all people in need of health services. In the short-term, quality health services delivery to the population needs strong collaboration and co- ordination between all stakeholders; the Federal Ministry of Health, the State Ministry of Health, NGOs, and the community.
According to an interviewee (2-9, 07 January 2011, El Fasher) in the State Ministry of Health:
North Darfur State has suffered from continuous civil war since 1980, between sedentary farmers and nomads in competition for natural resources.
In 2003, war broke out between rebel groups accusing the Khartoum government of marginalizing the Darfur region. This led to successive waves of massive population movement, coupled with drought and land degradation and severe loss of human resources (brain drain), especially in the health sector. All these factors have severely affected the health infrastructure and health status in the State. The conflict delayed development projects, including the health sector, most health facilities having been destroyed or affected by the conflict.
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He also disclosed that health workers struggle to cope due to the conflict. For example, in October 2009 the rebels were accused of attacking the joint teams from the Ministry of Health and NGOs, who were on their way to the Kutum district, and robbing them.
6.2.2.1 Consequences of conflict on curative health service delivery
According to the interviewees, conflict in North Darfur State has had a negative impact o n curative health service delivery, health system management and policy implementation.
This has been through creating poor conditions for health workers and by destroying most health facilities and communications, especially in rural areas. An additional impact is the lack of financial resources, because, as was explained in the previous chapter, government revenue has increasingly been directed to control the security situation.
The consequences of conflict on curative health service delivery system management and policy implementation in the State are outlined in Table 6.2. These factors emerged from the interviews that were conducted with health personnel in the public sector.
Table 6.2 The consequences of conflict for curative health service delivery system management and policy implementation in North Darfur State.
Inadequate resource availability:
Financial
1. Diversion of resources to security issues.
2. Reduced revenue for social services in general and health in particular.
3. Increased level of dependence on NGOs and donor funds.
Health workers:
1. Injured and kidnapped.
2. Displaced to urban areas, capital of country and out of country.
3. Poor morale.
4. Poorly paid, if at all especially those working in governme nt sector.
5. Disrupted training and supervision.
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Equipment and supplies:
1. Lack of maintenance.
2. Lack of drugs.
3. Reduced provision of modern technologies.
4. Inability to maintain cold chain due to unavailability of electricity.
Service Infrastructures:
1. Destruction of clinics and basic health units.
2. Destruction of bridges.
3. Lack of electricity supplies.
4. Disrupted referral and communications in general.
Management and organization of health service delivery:
1. Diversion from development based programs to emergency care.
2. More centralized, urban-based, vertical programmes and ignorance of horizontal programs.
3. Increased dependence on simple programs and ignorance of complex programs.
4. Focus on the short term system.
5. Lack of consultation on management and organization of health services.
6. Lack of data for evaluation and decision- making.
7. Limited management training for health staff.
8. Lack of capability to monitor funds and resources.
Changes in health service delivery situation:
1. Shift from primary to secondary care, such as curative health services.
2. Decreased activity of health service delivery in remote and rural areas.
3. Increased provision of health service in urban areas.
4. Disrupted campaigns of disease control, health promotion, and population outreach.
5. Reduced access to and utilization of public health facilities by increasing the fees of health services.
6. Increased private provision of health services, especially private clinics.
127 Source: Interviews, December 2010.
Due to the conflict, health workers are in constant danger if they are not in the urban areas.
Even so, they are poorly and irregularly paid if they are in government service. In dealing with the conflict, less government revenue has become available for the health sector, which has become increasingly reliant on assistance from NGOs and external donors.
The conflict has led to a breakdown in health infrastructure and supplies. This has affected how the health system itself is managed, with an emphasis on emergency care and centralising treatment in urban locations. The remote, rural areas consequently receive less health services, where primary health care has suffered, diseases are controlled less effectively, and training and monitoring are neglected.