Human and Financial Resources for Curative Health Service Delivery in North Darfur State
5.2 Human resources for health service delivery in North Darfur State
5.2.1 Distribution of health staff in North Darfur State
5.2.1.1 Distribution of doctors at district level in North Darfur State
Table 5.5 shows significant disparities in the distribution of health personnel according to population size at district level in North Darfur State.
Table 5.5 Distribution of doctors at district level in North Darfur State, 2010.
Districts Population size
No of
Specialists
No of
Deputy specialists
No of General doctors
Ratio of doctors per 100 000 population
Specialists Deputy specialists
General doctors
El Fasher 787 880 30 18 83 4 2.3 10.6
El Koma 29 574 0 0 1 0 0 3.4
Kalamondo 71 098 0 0 0 0 0 0
Millet 125 771 0 0 5 0 0 4
Dar El
Salaam
109 456 0 0 1 0 0 1
El Malha 64 113 0 0 2 0 0 3.2
Kutum 196 942 0 0 5 0 0 2.6
El Sireaf 73 840 0 0 1 0 0 1.4
Saraf Omra 119 456 0 0 1 0 0 0.9
El Liyit 93 878 0 0 1 0 0 1.1
El Towasha 89 704 0 0 1 0 0 1.2
Umm Kaddada
89 895 0 0 2 0 0 2.3
El Tina 0 0 0 1 0 0 0
El Waha 64 113 0 0 0 0 0 0
Kabkabeiya 197 446 0 0 2 0 0 1.1
Total 2 113 626 30 18 107 1.5 0.9 5.2
Sources: Central Bureau of Statistics, 2008; State Ministry of Health Survey Report, 2010 and Fieldwork Data, December 2010.
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It can be seen that deputy specialist doctors and specialists are concentrated in El Fasher, as shown in Table 5. 6 below.
Table 5.6 The ratio of doctors between El Fasher District and other Districts in North Darfur State, 2010.
Types of doctor Ratio of doctors between El Fasher district and other districts El Fasher district Other districts
Deputy specialist 100% 0%
Specialist 100% 0%
General doctor 77% 23%
Dentist 100% 0%
Pharmacist 100% 0%
Source: Calculated from the State Ministry of Health Survey Report, December, 2010.
Only 23% of general doctors are working outside El Fasher district and there are no deputy specialists, specialists, dentists or pharmacists working in other districts in the State. There are districts such as Kalamondo, with 71 098 people, without any health facilities and health staff, and districts like El Tina with one rural hospital and one doctor but with no population. Also in many districts, such as Saraf Omara with 119 456 people, Dar El Salaam with 109 456 people, and El Liyit with 93 878 people, there is approximately one doctor per 100 000 population.
North Darfur State faces a lack of health personnel in secondary level institutions such as district hospitals. Health centres also tend to have insufficient numbers of health personnel. For example, 22 out of 30 specialist doctors are working at the El Fasher teaching hospital alone and there are none working in district hospitals. 77% of all doctors are in El Fasher hospitals, leaving only 23% of doctors in the other 10 district hospitals. This lack of health personnel at secondary level is a serious problem and affects primary level institutions in North Darfur State in delivering a proper curative health service to the population. This causes patients to bypass the referral system (SMoH Report, 2009).
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The uneven distribution of doctors and specialists across North Darfur Sate was revealed in interviews. According to an interviewee (1-1, 05 January 2011, El Fasher) in El Fasher hospital:
The reason for the disparity in distribution is the demand for services itself. An urban area such as El Fasher has tertiary hospitals, such as a teaching hospital and specialist hospitals. These hospitals have a large number of health personnel, and they care not only for people within a district but also for people from other regions and neighbouring countries such as Chad. Another reason for the inequality in distribution is that after working hours, these doctors work in private institutions, increasing their income from working just working hours in district health facilities.
Due to the conflict situation in North Darfur State, an interviewee (2-1, 23 December 2010, El Fasher) in the State Ministry of Health, pointed out that:
Health staff, especially doctors, usually refuse to work in conflict-affected areas due to the security issues and bad working environment. For example, in El Tina district, located on the border with Chad in the west, there is only one doctor, and he works there because he is from that district. No other doctor wants to go there because the district is located in a conflict-affected area. In this manner, there is a huge differentiation in cadre vacancies among districts in North Darfur State.
According to Samb (2009: 2154), a strong positive correlation exists between health workforce- density, service coverage and health outcomes, indicating the importance of the health workforce for the health of populations. Shortages in human resources for health have been widely reported as the main obstacle to increasing interventions which are specific to certain diseases.
According to an interviewee (1-2, 05 January 2011, El Fasher) working in Dar El Salaam rural hospital:
I have been working alone as a doctor and administrator at the same time in the hospital. Sometimes I travel to El Fasher to bring medicines and some equipment and usually I spend two or three days to get that because the process to find medicines and equipment from the Ministry of Health is very complicated. Sick
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people come to the hospital and find no doctor available but they find medical assistants and nurses and those are usually dealing with serious cases. They don‟t have enough experience to treat patients or the problem of no drugs and other facilities.
He also disclosed that:
I travel a lot to El Fasher to meet the general manager of the State Ministry of Health to solve problems of health issues which are difficult to solve at district level. When patients do not find me, they have two choices: wait until I come back;
or continue to travel to search for other hospitals, maybe needing another six hours to reach the hospital in El Fasher. Therefore many patients die due to the absence of doctors in rural hospitals.
According to an interviewee (1-3, 10 January 2011, El Fasher) working in El Towasha district hospital:
Rural hospitals face a lack of doctors and bad working environments. For example, there is only one doctor in the hospital and I‟m receiving around 90-120 patients daily in the rainy season when the number of people with malaria increases. We don‟t have enough equipment to treat patients, and we don‟t even have oxygen to save people‟s lives in emergencies. We also don‟t have free medicine; the only one thing we have free is death certificates. Every treatment we claimed, patients bought the medicine from private pharmacies with their own money.
Regarding hospital beds, he said, „We don‟t have enough beds in the hospitals, we have only 23 beds‟. When asked why he didn‟t report these proble ms to the state health officer to solve, he said that he did, but that the officers didn‟t respond. When asked whether he had requested aid assistance from NGOs working in the health field in the district, he said that there were no NGOs now working in El Towasha district.
This situation confirms Mahmoud‟s study (2010), which stated that it is not surprising to find an abandoned dispensary, a rural hospital without doctors or a health unit without medicine in Darfur.
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According to Badr (2007:26), the wages of health workers are generally low compared to those for other public sector employees within the civil service. Several categories, such as judges and oil engineers, enjoy exceptionally high wages of more than double that of doctors. In the health sector, doctors, in addition to dentists and pharmacists, are better remunerated than nurses, technicians and other allied health personnel.
The gradient difference in salary between the public and private sector for health workers is wide and in favour of those employed by private sector institutions. According to an interviewee (1-4, 04 December 2010, El Fasher) employed by in El Fasher teaching hospital, „physicians‟ salaries are very low (US$ 200 per month) compared to those of other equivalent professio nally trained persons in the private sector, especially those working with NGOs (US$ 1 000 per month at least)‟. (See, too, Badr (2007:26)).Therefore Medical Officers in North Darfur State tend to work at private hospitals after they finish their duty at p ublic hospitals, in order to earn an additional salary, even if they remain in the public sector. The State Ministry of Health Financial Report (2009) also pointed out that salaries are paid irregularly, especially outside Khartoum. This explains the high attrition rate of doctors in the public sector. 50% of them leave, either for private practice, or move to another country (State Ministry of Health Survey Report, 2009).