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
6.2.5 Lack of trust between the authorities at federal, state and district levels
According to Walker and Gilson (2004:1251), the gap between policy objectives and outcomes is a demonstration of how policy is recreated through the process of implementation, rather than an implementation failure; developing inter-personal competence and trust within organizations is necessary to strengthen policy implementation. Health system management and policy implementation do not produce a good quality health service without strong relationships and high levels of trust between all levels, federal, state, and district, which are necessary in order to address health service issues and to solve problems. As shown in Table 6.7 below, 88% of interviewees at all levels and 95% of interviewees at district level pointed out that there is a lack of trust between the authorities at federal, state and district levels regarding their r esponsibilities in managing and implementing health systems and policy. This is clear est at district level, where all but one interviewee indicated that the authorities at federal and State level do not trust the abilities of district officials to manage and implement health systems and policy.
134
Table 6.5 Interviewees‟ responses about the lack of trust between the authorities at federal, state and district level in managing and implementing health system and policy in North Darfur State.
Government levels
The number of responses
Type of response Percentage (%) Trust Luck of
trust
Trust Luck of trust
Total
Federal level 3 1 2 33% 67% 100%
North Darfur State level
18 3 15 17% 83% 100%
Districts level 21 1 20 5% 95% 100%
Total 42 5 37 12% 88% 100%
Source: Fieldwork Data, December 2010.
According to an interviewee (2-13, 27 January 2011, Khartoum) employed in the Federal Ministry of Health as a general manager of health policy and planning:
The Federal Ministry of Health does not have enough qualified health administration staff to send to the State to train the state health staff in managing and implementing health systems and policy effectively, and at the same time, we don‟t have enough of a budget to do that. Meanwhile there is a lack of qualified health administration staff and we don‟t trust them to participate in the health policy design process because they don‟t have enough skills. Therefore health system management and policy implementation is not working properly in any of the states in Sudan, not only in North Darfur State.
According to an interviewee (2-14, 23 January 2011, El Fasher) in the State Ministry of Health:
The central officers don‟t trust the State officers in their technical skills of managing and implementing health systems and policy. The FMoH officials perceive their role to be that of the initiation of guidelines for technical programmes - something that they feel can be done at the Ministry headquarters without the need to consult state health authorities, who are not
135
qualified. If the latter must be consulted, state staff can be summoned to headquarters in Khartoum.
This same interviewee believes that the State has little to contribute to the health policy process at the central level. This in turn results in a lack of participation and lack of ownership of policies by the people in State government who are responsible for their actual implementation. Further, the finalized policy guidelines have not always been effectively distributed to the implementers. Many complaints were heard about extensive interference in the operation of technical programmes in the State by the central level. A main complaint concerned the lack of interaction in technical support. The weakness of the relationship between the central and State levels, particularly with regard to technical programmes on managing and implementing health policy effectively, was observed at State level. The lack of trust in the relationship b locks fruitful collaboration between the federal government and North Darfur State.
According to an interviewee (1-7, 19 January 2011, El Fasher) who is a bureaucrat in Mallit district rural hospital:
We don‟t have administrative health staff but a specialist in health system management and policy implementation and he is a doctor. He knows that health system management is very important, especially at district level because the districts assumed the responsibility of health policy implementation.
The interviewee also mentioned that:
All this doctor does about health system management and policy implementation is at the end of every month to send the State health department reports about the situation of health service delivery and the difficulties which face us. Usually when we ask them to give us some funds to manage and implement the health system and policy, they don‟t trust that we have skills to manage mo ney and manage and implement health systems and policy; they think we do not understand the objectives of health policy.
136 The interviewee also explained that:
They are right because they didn‟t consult us about health policy design and its implementation process, nor about what problems we faced to manage that effectively. By giving communities space to make their own decisions, they may well manage and implement health systems and policy and be accountable, something that could never come from a top-down strategy.
According to the interviewees, health information in North Darfur State is not produced on a regular basis. This challenge is broadly recognized by all the government sectors, not only the health sector, whether at federal, state or district level, and a major effort has been underway by the National Bureau of Statistics which began in 2008 but has yet to release final results. Therefore little progress has been made so far in improving the quality and availability of health information, expenditure patterns, and quality of curative service delivery.
Even the limited statistics on the health sector are not made publicly available. In part, this is due to the conflict situation in the State, since there is considerable reluctance to reveal information on government performance. As was discussed earlier in this chapter, insufficient information sharing across various health institutions at the three administrative levels is a fundamental weakness of the existing inter- governmental arrangements in North Darfur State in managing and implementing health system and policy. Thus information in the public health sector is limited because of a lack of trust.
Yet this absence of trust prevents proper co-ordination between the levels of government in furthering curative health services in North Darfur State.