Co-ordination between Federal, State and District Levels in Managing Health Systems and Policy Implementation in North Darfur State
6.3 Managing co-ordination between levels of government
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.
137
According to most interviewees‟ views, intergovernmental co-ordination between federal, State and district level in managing and implementing health systems and policy in North Darfur State, currently face two general challenges. Firstly, the Federal Ministry of Health has neither the capacity nor an effective mandate to monitor and co-ordinate the State Ministry of Health‟s performance. It does not have practical measures to influence the State Ministry of Health‟s projects nor direct methods of health system management and policy implementation. Secondly, the State Health Ministry‟s managers perceive themselves as independent in the extreme with little interest in information sharing and in participating in joint projects with the Federal Ministry. The NHP describes the responsibilities of the state level as that of policy implementer, which means that they are supposed to work in co-ordination, not isolation. This situation is aggra vated by the generally weak co-ordination of State and federal levels.
The regular supervision of health services at lower levels by higher levels is necessary in order to ensure acceptable medical and administrative standards. The supervisory visits by government officials are seen as an effective method of health system administrative control of the flow of the health policy implementation process at lower levels.
As shown in Table 6.6 below, 90% of interviewees at all levels and 100% of interviewees at district level stated that the situation of supervision of the health service delivery situation and policy management and implementation in the state is very weak.
Table 6.6 Interviewees‟ responses about effectiveness of supervision of health service delivery between Federal, State and District levels in North Darfur State.
Government levels
The number of responses
Type of response Percentage (%)
Yes No Yes No Total
Federal level 3 2 1 67% 33% 100%
North Darfur State level
18 2 16 11% 89% 100%
Districts level 21 0 21 0% 100% 100%
Total 42 4 38 10% 90% 100%
Source: Fieldwork Data, December 2010
138
The regular supervision of health institutions and administration at district level is very weak because, as all health professionals and administrators working there pointed out, officials from State government do not visit the districts regularly in order to evaluate the situation of curative health service delivery and the process of health policy implementation in local communities.
According to an interviewee (2-15, 24 December 2010, El Fasher) working in the State Ministry of Health:
There are no regular supervisory visitors from the State Ministry of Health to the district levels to supervise the situation of curative health service delivery, because there are many problems hindering that, such as insecurity issues, the small number of administrators in the State Ministry of Health, security of financial resources, and the unavailability of vehicles to visit health facilities at district level.
According to another interviewee (2-16, 09 January 2011, El Fasher) also in the State Ministry of Health:
The collaboration and co-ordination between federal and State levels is very weak because there are no complete teams from all departments at the Federal Ministry of Health to annually visit the State Ministry of Health to monitor and evaluate the situation of health policy implementation in the State. They usually come as individuals from departments at federal level to the equivalent department at State level but even these visits are not regular. The Federal Ministry of Health‟s strategy for evaluating the situation of health policy at state level is to send reports from state to federal level but these are not periodic reports, which are necessary for identifying serious problems such as idiomatic diseases.
According to an interviewee (1-8, 12 January 2011, El Fasher) working in El Towasha rural hospital:
139
I have been working here for three years and the hospital is never visited by health administration teams or individuals to see our problems in curative health services provision or the problems that face us in managing health systems and in implementing policy. The a uthorities at State level usually promise to solve our problems soon, but after we leave the town no one cares about the district‟s health problems. The State Ministry of Health is not interested in the availability of curative health services at district level and how it can concern itself with health system management and policy implementation.
This view confirms findings in the SMoH Survey Report (2010), which stated that the poor health services infrastructure and insecurity issues in North Darfur State affect the curative health service delivery system. The destruction of health facilities, blockades of essential supplies such as appliances and equipment, and restrictions on drug movements by health workers, have caused serious difficulties in enabling supervisory and monitoring visits by State and district health teams to take place. Here again this has been made even more difficult by the three levels of governments not assuming their responsibilities of health system management and policy implementation. Those in federal government do not have confidence in the expertise and experience of those at the State and district levels, whereas the latter believe that the federal level has neglected them in decision-making and does not support them with enough resources and facilities.