Improving the Effectiveness of the Curative Health Services in North Darfur 8.1 Introduction
8.6 Co-ordination between the federal, State and district levels of government
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available, this could lead to another set of issues. The experience of countries that have removed fees is that this has led an increase in the utilization of health services, especially for the poor.
This means an increase both in the workload of health staff and in drug consumption, which highlights an even greater need for more human and financial resources.
The distribution of public funding for curative health services depends on how co-ordination is practised between three levels of government.
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integrate information, planning, and management systems to facilitate this process. To address this, the government needs to build the capacity of the State Ministry of Health, as well as that of the district health authorities. It is planned to provide electricity, internet, and software, for supporting the design of a standardized and integrated database, and to link all health facilities in the districts with the State and with the Federal Ministries of Health to exchange health information, and to monitor health system management and policy implementation. The public sector needs to involve the private sector, including international NGOs, as the health sector requires technical, economic, managerial, and political partnerships.
According to an interviewee (2-11, 22 December 2011, El Fasher) in the State Ministry of Health:
To address the problems that face health system management and policy implementation in a decentralization system, the government at all levels should remove the constraints that hinder the provision of quality curative health services. Constraints include: lack of financial resources, non-availability of health infrastructure, especially at district levels;
and a lack of competent personnel in adequate numbers to serve in numerous health facilities, especially in remote rural areas. There are poor communication facilities to obtain health information, and there is a lack of adequate transport facilities to transport medical supplies. All these factors affect scaling up hea lth services, effective health system management, and policy implementation.
Both the health administrators above show a clear overall understanding of what is required in general terms in order to achieve a much improved degree of co-ordination between the levels of government. Others spoke of more specific aspects of co-ordination.
The consequences of conflict on managing curative health service delivery system and policy implementation include the issues of financial and human resources, equipment and supplies, service infrastructure, and the organization of health service delivery (see Chapter Six, section 6.3 and Table: 6.2).
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Conflict in the region has badly affected transport and communication. Because of road blocks and the destruction of bridges and communication towers, supplies of commodities, equipment and drugs throughout North Darfur State have become difficult and uncertain.
According to an interviewee (1-8, 11 December 2010, El Fasher) in Mellit Rural Hospital:
We are supposed to visit each facility on a monthly basis to supply commodities, review health system management data and support front- line staff. But due to the insecurity and lack of vehicles such supervisory visits were infrequent and not always supportive. To do this we need security and more vehicles and fuel, because we experienced breakdown of vehicles and unavailability of fuel, compound the situation.
How could communication be improved in these circumstances? According to an interviewee (2-12, 16 January 2011, El Fasher) in the State Ministry of Health:
For a better and an active communication system between the three levels of government, the government should organize for the federal, State and district levels to indicate the lines or channels of reporting and communication. There is a demand for clarity on channels of reporting and communication and for functioning communication facilities to coordinate the district, State, and federal levels.
Also the interviewee said:
The system should put in place regular, structured communication which needs effective communication infrastructure which includes internet communication, telephones and computers, especially at the district and State levels. Internet connection needs to be installed in all levels, which will enable all departments and administrat ive offices to access the internet, but the government needs to provide electricity supplies first. Also the health councils for information sharing at district and State level must meet monthly to evaluate the situation of health service delivery and health system management because sometimes they meet only once a year for feedback. Without adequate and timely communication between the three levels, district, State and federal, health management teams cannot effectively fulfill their oversight role.
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More effective co-ordination therefore requires infrastructure and equipment to make communication easier, but it also requires more active management to ensure that officials meet regularly to deal with issues regarding the delivery of health services. Co-ordination also entails the transfer of resources and information between the levels of government.
According to an interviewee (2-13, 23 December 2010, El Fasher) working in Kutum Rural Hospital:
We who are working at district level suffer from a lack of resources and delays in transferring them from El Fasher. We need co-ordination between State and district in terms of transferring the funds to be stronger. Due to the bad secur ity situation we need the district authorities to supply us with money which is collected locally from taxes and so on, instead of first transferring this to El Fasher. The State authorities took our funds from Millet district. We need funding to be guaranteed on time so that we can deliver health services.
According to an interviewee (2-14, 25 December 20101, El Fasher) in the State Ministry of Health Finance Division:
We receive very few funds from the federal level except the health workers‟ salaries, but the authorities at federal level usually delay in transferring the funds to us. Although the transfer takes place through the Bank we don‟t know why they delay. Their justification is that they didn‟t receive the funds on time from the Ministry of Finance which means that there is a complicated bureaucracy of transfer. In my view I suggest that the federal authorities should put one month‟s funds in reserve so that transfers can happen on time at the end of each month to poor states such as North Darfur State.
Two mechanisms in improving the flow of public revenue to the districts are suggested above.
One is essentially for the districts to collect the revenue themselves that is due to North Darfur State from federal government. Again, this is a call to simplify processes by avoiding the State level altogether. Secondly, there is the view that the federal government should maintain a
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constant reserve of revenue so that there need not be any delay in regular transfers to lower levels of government.
Curative health services require co-ordination in relation to accurate data and information (see section 6.4.2 and Table 6.5). This was seen as a widespread problem by 88% of the interviewees.
According to an interviewee (1-9, 27 December 2010, El Fasher) working in El Towasha Rural Hospital:
For a good data collection system there is a need for standard data collection tools for the routine data collection procedures. To do this there is a need to develop unified system registers for collecting informatio n from patients in health facilities. The facilities administration should send a mortality and morbidity report to the State Ministry of Health; and the government must fund vertical programmes to obtain reports by virtue of programme data collectors or contracts for services providers that link funds to performance and monitoring. Also there is a need for improvement of the capacity for data collection and analysis, and monitoring and evaluation knowledge at district and State levels. Data collection and basic aggregation and analysis must happen in health facilities. Without operational district health departments‟ data collection and data flow reports feedback of the routine health information system do es not follow the management lines of the health system. Data flows from health facilities to the State level and from State level to the federal level is really necessary and needs to be over the internet to get feedback quickly from the lower level to the high level and vice versa.
The interview also disclosed that:
Districts and the State are bypassed on the assumption of their low capacity, but feedback to lower levels is mostly needed. In addition to that, the monitoring and evaluation system has challenges which need to be solved by government and its partners. These challenges include: poor coverage of information technology equipment to analyze and process data at state level; limited power sources in district areas; communication and transportation problems for data to be transmitted from the collection to the processing points and no effective delegation for decision making and action.