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
6.2.3 Distance and communication
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.
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According to an interviewee (2-10, 28 December 2010, El Fasher) working in El Malha district:
Due to the distance from El Fasher, from where we receive our health service supplies, in the rainy season we sometimes go a week without some health supplies and drugs. As we don‟t have a vehicle of our own, we have no choice but to wait until private transport delivers our supplies. Also due to the distance, no one from the State Ministry of Health visits to check on the quality of health services delivery and what problems we face. As such, we work in very bad conditions and this prohibits us from managing the health system and implementing health policy as should be the case.
According to an interviewee (1-4, 19 January 2011, El Fasher) working in El Tina rural hospital:
Due to the distance between El Fasher and El Tina on the Chad border (300 kilometres), sometimes we run out of necessities such as trauma drugs and oxygen for two or three weeks. Due to the insecurity situation, we usually receive our health care needs through the African Union/United Nation Hybrid Operation in Darfur (UNIMED) helicopters.
Due to the long distances and poor roads between Khartoum and El Fasher, and between El Fasher and the district administration, health service delivery staff and authorities work in isolation. To some extent, means of communication can overcome the challenges of distance. But communication in the health system in North Darfur State has itself been problematic.
Effective communication between all levels of health service delivery is an important factor in the health sector. Clearly communicated channels provide direction and certainty for all actors and contribute to effective implementation of health policy. As shown in Table 6.5 below, 88% of interviewees at all levels, 83% at State level and 95% of interviewees at district level indicated that health system management and policy
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implementation have been facing difficulties of poor communications tools between federal, state and district levels in North Darfur State.
Table 6.3 Interviewees‟ responses about effectiveness of communication tools between federal, state and district levels in North Darfur State.
Government level The number of responses
Type of response Percentage (%)
Yes No Yes No Total
Federal level 3 1 2 33% 67% 100%
North Darfur State level
18 3 15 17% 83% 100%
District level 21 1 20 5% 95% 100%
Total 42 5 37 12% 88% 100%
Source: Fieldwork Data, December 2010.
During the interviews, health practitioners in government acknowledged that the implementation process suffers from communication gaps between the levels. They also disclosed that these gaps prevent the flow of information from lower to upper levels, particularly in understanding the problems which face curative health service provision at district level. All interviewees acknowledged that they are working in semi- isolation from one another because communication facilities such as public telephones, cell phones, and internet service are not available, especially at district level. These types of communication equipment are very effective and efficient in referral systems, linking all levels. Such equipment allows feedback to the original referral point, in order that difficulties facing district levels in providing and strengthening the continuity and quality of curative health services may be known.
Such difficulties in communication were recognised earlier by the SMoH Report (2009).
The FMoH has a co-ordination and communications office within the Directorate of External Assistance and Co-ordination for strengthening communication within the FMoH, the government Directorates, and the SMoH. However, there is still a lack of clarity on channels of reporting and communications, as well as a lack of a functioning communications protocol between federal, state and district levels. There are no systems in
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place for regular, structured communication, either with states or with other health partners such as NGOs.
Communication between federal and state levels is itself weak and is characterized by inadequate and inconsistent reporting, information gathering and feedback. This has resulted in a lack of clarity among health staff regarding key health policies, and poor information sharing, inadequate use of evidence to support decision- making and insufficient support provided to staff.
According to an interviewee (1-5, 28 December, El Fasher) working in Kepkabiya district hospital:
Due to the conflict, the communication situation between State and district is very difficult; because not all communications tools to communicate with State level are available. Some remote districts such as Kepkabiya, El Tina and El Malha have been using UNAMID helicopters and NGOs vehicles to communicate with El Fasher the capital of the State to receive some medicines, appliances and equipment, especially in rain seasons.
According to another interviewee (1-6 27 December, El Fasher) working in El Tina rural hospital:
There is limited communication infrastructure (internet, telephones and computers), especially at State level and a complete absence at district level.
An internet connection is being installed in the State Ministry of Health by WHO but it is not accessible all the time because of unsustainable electricity supply and service problems which have been solved by UNAMID and other organization.
For example, due to the lack of electricity supply in most health facilities, especially in rural areas, UNAMID and other international organizations try to provide electricity generators for health facilities, as shown in Figure 6. 1 below.
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Figure 6.1 El Tina district hospital, generator provided by UNAMID (27/08/2011).
This lack of communication undermines health policy development, stakeholder engagement and ownership, and health policy implementation on the ground. Without adequate and timely communication, between federal, state and district levels, health management teams cannot effectively fulfill their supervisory roles, nor manage and implement health policy effectively.