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
6.2.1 Decentralization
6.2.1.3 Service delivery management and policy implementation
The responsibility for managing health institutions and facilities and monitoring service providers belongs, as seen in Table 6.1, to the State and district levels, but the issue is whether they are able to carry this out. The responsibility for contracts with health providers, payment mechanisms and regulations, providing services for targeted people and providing medicines and supplies are mainly transfers from the federal government, but in reality these are left for State and district levels, as was disclosed by interviewees.
According to an interviewee (2-3, 23 December 2010, El Fasher) in the Federal Ministry of Health:
The federal level has a right to sign contracts for international NGOs and donors to provide health services especially in conflict-affected areas such as North Darfur State. This is not difficult for the government because it does not cost them any
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money, but problems come when the federal level takes the responsibility for payment mechanisms and regulations and is not able to activate this task. The health administrators at State level are complaining about the system of payment.
For example, some State administrators receive their salaries very late and no one at the federal level cares about this. This has resulted from the weakness of the payment mechanism system. Also sometimes the transfer of health equipment from federal to state to district level takes months to arrive.
The interviewee also mentioned that:
The regulations are not active even at federal level let alo ne at the state and district level. Providing services for targeted people who are affected by conflict or epidemics is the responsibility of international NGOs, not federal or state levels.
Currently the public health facilities have been supported by NGOs in providing medicines, especially life-saving drugs and other necessary supplies such as electricity to the poor and vulnerable people in North Darfur State.
According to Table 6.1 the federal government is responsible for policy design.
Supervision and evaluation are shared between federal and state levels, while districts are mainly responsible for implementing policies. How this was realised in practice was expressed in interviews with public health officials in all three levels of government.
According to an interviewee (2-4, 3 February 2011, Khartoum) in the Federal Ministry of Health:
Sudan applied decentralized administrative procedures to the lower levels but it is still strengthening central control over policy design and budgetary activities; decentralization is very sensitive in that it is concerned with the distribution of power and the locations of resources. The implementation of NHP in a decentralized system requires strong political commitment to achieve a good result. In North Darfur State, the State Ministry of Health is unwilling to implement NHP effectively because state and district authorities have been reluctant to accept their new responsibilities of power without resources.
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According to an interviewee (2-5, 22 December, El Fasher) in the State Ministry of Health:
Poor states such as North Darfur State do not have enough resources to meet their commitments regarding their responsibility to implement health policy successfully. In North Darfur State we struggle with insecurity regarding the financing of health services. We also don‟t have enough health administration staff and those that we do have don‟t have any training in how to manage and implement health systems and policies. Since 2002 we haven‟t received any budget from federal government for development of the health sector, and without these budgets, we are unable to manage and implement health systems and policies in the State.
According to an interviewee (1-1, 26 December 2010, El Fasher) in El Towas ha district hospital:
We don‟t have administration staff to control health policy implementation.
I‟m a doctor and administrator at the same time and I‟m busy treating patients; I don‟t have time to manage health policy as well. The authorities at state level don‟t consult us when they are designing health policy and we are responsible for its implementation; we should be involved at the decision- making stage of health policy design.
According to an interviewee (1-2, 21 January 2011, El Fasher) in El Malha district hospital:
A decentralized health system without qualified administration staff, good means of transport, modern equipment and enough funds to finance health services and to pay for health staff, cannot succeed at district level and achieve its objectives. We constantly complain about the poor situation of the health service delivery system, especially at district level. Implementing health policy in decentralized structures in North Darfur State represents an arena of struggle between a local level wanting more funding and autonomy, and a central level not providing adequate budgets to the lower levels.
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Operational maintenance of health facilities and infrastructure, provision of vehicles, equipment, and communication tools, is mainly the responsibility of State government, as Table 6.1 indicates.
According to an interviewee (2-6, 20 December 2010, El Fasher) in the State Ministry of Health:
Because North Darfur State experienced a lack of natural, human and economic resources as well as conflict, the health facilities infrastructure became very poor.
Health facilities, especially in rural areas, were looted and destroyed and other health infrastructure issues still beleaguer the existing health facilities, including inadequate and/or complete lack of medical equipment, transport and communication equipment, water and energy, all of which are required for the health infrastructure to be fully functional.