Improving the Effectiveness of the Curative Health Services in North Darfur 8.1 Introduction
8.2 The structure of the health system in Sudan and North Darfur State
In Sudan, the decentralised system which consists of three levels, federal, state and district, where each level has certain specific responsibilities to manage the health s ystem and to deliver health services. The federal level is responsible for health policy formulation, whereas the districts implement health programmes locally. At each level there is a health structure and administrative committee but, as has been reported, they are not as active as they should be and need to be developed. This requires adequate health financial resources, appropriate staffing and modern communication facilities in order to enable the health committees to hold their meetings properly. The views, opinions and experiences of health workers at lower levels regarding health system management and policy implementation needed to be forwarded regularly to the policy makers and planners at higher levels as feedback in order to improve curative health service delivery and the health policy process as whole.
Due to the lack of human and financial resources, especially at district level, these health committees are not able to hold their meetings to discuss the problems and obstacles that face the
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provision of health services, management of the health system and policy implementation.
Therefore there is weak capacity at all levels of governance in the health sector in North Darfur State. In addition to the lack of resources, the managerial capacity is not adequate to cope with the requirements of a decentralized health system. Such a situation impacts not only on the overall management but also on the delivery of curative health services.
Consequently, the structure of the health system has turned out to be weak in practice because the health committees at all three levels are not able to fulfil their responsibilities, which leads to failure in policy implementation and health system management. As a result, many of the objectives of NHP 2007 have not been achieved. (see Chapter 3, section 3.6, Tables 3.2-3.7.) How can the structure of the health system be strengthened?
According to an interviewee (2-1, 17 December 2010, El Fasher) in the State Ministry of Health:
In order to develop and strengthen the health system structure, the government should focus on building the capacity of health institutions with qualified personnel, more adequate materials and equipment, drugs and health infrastructure, which includes electricity supply, good roads, and modern communications facilities. Another area that needs to be addressed is a data collection system. The availability of reliable data on the quality of health service delivery is very important in the developing health s ystem structure. To do this, the government and its partners such as NGOs and UN agencies need to provide a database of health records. There needs to be personal interest by the State Minster of Health in reviewing data on particular health priorities, such as demanding to see monthly figures on the number of children who die with malaria. I think that the development of the health system structure depends on the approaches that the government follows to adapt the health system and policy and to consider the problems that face the health administrations at lower levels.
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According to another interviewee (2-2, 23 December, El Fasher) in the State Ministry of Health:
Currently the government designs health policy by applying top-down approaches which is very complex for us working at state level, because we have not been consulted in health system and policy design to know exactly what the health policy objectives are although we are the implementers of the policy. Therefore we need the government to change the model of health policy design. In a large country like Sudan each state has it is own problems and this needs to be considered in national health policy. The best way of health policy design and successful implementation in my view is a bottom-up approach which lets the authorities at district and state levels as well as communities participate in health policy design, because we know our health service problems. To participate effectively in health policy design according to local conditions and to implement it successfully, we need from government two main things: first give us more freedom to adapt the health programs to local conditions and needs which means full of trust ing us.
Secondly, provide us with more resources.
According to an interviewee (1-1, 15 December, 2010) working in Dar El Salam Rural Hospital:
In terms of the health policy process we are not part of it and usually the authorities at federal level ignore us even though we are the actual implementer of health policy. This has led to the failure of health policy implementation. In my view to design proper health policy and to implement it successfully and achieve its objectives, the district health office should initiate the formation of partnerships in health, as well as to plan, encourage, and motivate stakeholders and supervise implementation activities.
The interviewee also said that:
The federal level ignores those at lower levels, especially those at district level by implementing a top-down approach, which is, in my view, a key obstacle that delays, and possibly worse, undermines the implementation of health policy. These problems can be solved through applying bottom- up approaches which narrow the gap between perceptions of policy makers and those who know the conditions of local areas and provide and receive health related services. In the case of North Darfur State, which is affected by conflict, the government needs to involve the international NGOs in the
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health policy process, including national health policy design, because they have been providing more health services than government itself, which means they have been implementing health policy. Therefore, the national health system should avoid the rapid establishment of performance management systems that do not take stock or build on local decision-making powers and capabilities.
According to this interviewee, in order to develop the structure of the health system the government should focus on building the capacity of health institutions by supplying medical schools with qualified staff and materials, creating jobs opportunities a nd stopping the migration of qualified health staff. The health infrastructure needs more health facilities, electricity and water supplies, better roads and modern communications facilities. A health information database also needs to be created, especially at district level. How to do this? Government does not have the ability to do this on its own. It needs major assistance and support from donors and international NGOs to develop the structures of the health system.
Policy implementation is more important than its statement and formulation: what happens on the ground, not simply what is stated in the media or on paper, needs to be the measure of policy content and commitment (Zwi and Mills, 1995: 320). In a large country like Sudan, and in a large state like North Darfur State, the best way to implement health policy effectively, according to the views of the interviewees, is a bottom- up approach which empowers health staff who are working at lower levels such as districts to participate in policy formulation process. District health officials were critical that they were not formally represented on the committees that developed health policy, arguing that those who developed the policy did not understand the priority of health issues in local areas, and that they need to be included in health policy design.
Only by listening to, and learning from, health practitioners and officials, can the structures of the health system be adapted according to the particular needs of North Darfur State. This also implies attending to the issues of communication, as well as to the need to accumulate evidence for analysis by building adequate database for health services.
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