Health services in Sudan lecture 1

Health System Overview

Dr. Amani Elkhatim

Historical Background:
The modern health care system goes back to 1899, when it was being delivered by the army. The medical department was established in 1904 and in 1924 the Sudan Medical Services was established and became the Ministry of Health in 1949. In the period 1960-1971 the health was managed according to the Province Administration Act 1960. This was followed by the Popular Local Governance Rue in 1971.

Historical Background: The adoption of the federal system started in 1991. The nine regions of Sudan were upgraded into states that further became 26 states (currently 25 states). Each state has a Ministry of Health. Within each state there are number of localities (134 in total) managed through a district health system approach (DHSA) according to the 2003 Local Government Act.

The Health Administration Structure

There exists a three- layered health system structure; first layer is the Federal Ministry of Health (FMOH), secondly State Ministries of Health (SMOH), and local health system, as third layer. The local health system is based on DHSA. Its emphasis is on PHC based on decentralization, community participation, intersectoral coordination and integration of health services. Local councils are also responsible for water and sanitation services. The MOH GOSS is organized into a four tier system. It consists of the central level, state level, country and municipality level and community level (which include PHC centers, units and communities).

HS Sudan

Main HCP in Sudan

HCS Organization
Tertiary

Secondary

PHC

PHC
PHC has been adopted as a main strategy for health care provision in Sudan in 1976, reemphasized in the National Comprehensive strategy for Health in 1992, and reemphasized in the 25 years Strategic Health Plan 2003-2027 and in the 5 years Health strategy: 2007-2011 and in the interim health policy report of SS 2006-2011.

PHC facilities
The PHC facilities are comprised of health centers (HC), dispensaries, dressing stations (DS) and PHC units (PHCU). In 2005 there were 1043 (HC) of which 558 were urban and 485 rural, 1226dispenseries, 762 dressing station (DS) and 3044 PHCU. The least acceptable level for health services provision is a dispensary headed by a medical assistant and structured and staffed to deliver integrated PHC and health care programs and services.

PHC facilities
Rural hospitals are considered part of the PHC and serve as first level referral within the locality. According to a recent FMOH document in2007 only 22%of the existing PHC facilities are providing the minimum essential PHC package. As for Southern Sudan there are 19 hospitals, 574 PHCC and 15 training institutions. The majority is run by NGOs and Faith Based Organizations (FBOs). Most of the health facilities are concentrated around the state headquarters, especially former garrison towns.

Health Service Delivery

Health services in Sudan are provided through different providers and institutions including in addition to FMOH and state MOH, Armed Forces, Police, Universities, Private sector (both for profit and non-profit) and the civil society. However these different providers are providing services in a very uncoordinated system. The overall coverage of heath services is low with very marked urban- rural and regional disparities. There has been increased focus on establishing hospitals during the past 10 years from 253 in 1995 to 351 in 2004.

Health Service Delivery

A major player in the health care delivery in the two main areas that have witnessed distress and faced humanitarian crisis is NGOs. According to the governmental reports there are 53 active International NGOs, offering wide speared services. In SS 58% of health care workforce are employed by NGOs. The complex relations with different authorities such as Ministries of International Cooperation, Humanitarian Affairs, Foreign Affairs and SMOH make coordination a very difficult exercise. Also it is difficult to monitor and evaluate their activities.

Private Health Care System

Private health services are increasing significantly since they are perceived to be of better quality than government services. They are concentrated in urban areas and especially in Khartoum. The expansion has been mostly in curative care but not in preventive and PHC areas, although they are providing primary care. The cuts in funding of government health services combined with introduction of users fees, have contributed to growth of the private sector, which focuses mainly on curative services.

Private Health Care System

There are 172 private hospitals and medical centers, out of which 119 are located in Khartoum state. Khartoum share of private clinics equals 739 specialist clinics, 539 GP clinics, 288 dental clinics, 799 private laboratories, 30 x-ray units 17 physiotherapy clinics, 195 public pharmacies and 1220 private pharmacies.

Health Expenditure Data and Trends

The public health spending in Sudan is low; it is in the range of 0.4-0.9% of the GDP- The least WHO recommended spending is 5%. Spending at the federal level is through FMOH budget (3-4 US$ per capita) and social security which is equivalent to 1-2 US$ per capita. The magnitude of the private out of pocket expenditure is estimated to be as high as 70% of the total health expenditure.

Health care Workforce

The total health care workforce is estimated as 62,483 health personnel classified into more than 20 categories. There is shortage of most categories of health care workers. Moreover there is uneven distribution of the workforce between and within states, the above motioned ratios hide inequalities between urban-rural and between states. Although PHC is the main route for provision of health care its share of health care workers is very meager. As for Southern Sudan most of health workers are employed by NGOs and FBOs (578%), the GOSS employs 23% while SPLA 5%.

Training
Although many stake holders are involved in training the different categories of the workforce (FMOH, SMOH, Police, Military health services, universities, the private sector and NGOs), coordination between these organizations is very poor. There are 26 medical schools with an annual enrolment of 2200 with an expected graduation in the coming five years to be 2600. There are 13 institutes for training of medical assistants (MAs) and 38 midwifery schools with an annual graduation of 320 MA and 1400 midwives respectively.

Training
The new Academy of Health science at FMOH is planned to graduate different categories of health workers. In 1994 the higher council for teaching hospitals and specialized medical centers was established to set levels and standards of medical services and performance.

Environmental Health Services

The leading causes of morbidity and mortality are environment associated or related. Only 60% and 31% of the population has access to improved drinking water and improved sanitation facilities respectively. There are very marked regional and urban- rural variations. Moreover, the weak environmental health services are further aggravated by the displaced and population movement which resulted in creating unhealthy shanty towns and slums at the periphery of big towns and cities. Health education programs are also weak and have no impacts.

Sudan current level of relevant health MDGs and the targets of 2015- National and SS: SHHS 2006
MDG MDG 1: Poverty and Hunger Poverty incidence (% of total population)2000 Prevalence of child malnutrition- underweight for age, U5 population)Prevalence of acute child malnutrition(underweight for height, U5 population)MDG 4: child Mortality U5 Mortality rate ( per 1000 LB) MDG 5: Maternal Mortality Maternal Mortality Ratio (per 100, 000 LB) MDG 6: HIV/AIDS, Malaria and TB HIV prevalence (% among adult age 15- 49 years) Incidence of TB (per 100,000 per year) Children U5 with fever and treated with antimalarial National 29.6% 31% North 50-90% 35% 16% 2015 target 25-45 16% 8% South 90% 48% 21% 2015 target 45% 24% 11%

72 638

104 509

35 127

250 2030

83 425

1.6% -

1.6% 90 33%

2.6% 325 36%

lecture 2 Introduction to Health System

Health Systems
Combination of resources, organization, financing, and management that culminates in the delivery of health services to the population
Roemer MI. National health systems of the world, volume 1. New York, Oxford University Press, 1991

All activities whose primary purpose is to promote, restore and maintain health
World Health Report 2000

Health systems
Health system comprises three highly interdependent elements: Ecosystem - socio-cultural, demographic, economic and political surroundings Health Care Delivery System based on health problems and needs, health inputs, distribution, output, utilization and outcomes; Community Involvement organization, awareness, contribution and utilization

Health system
Ecosystem
Health Care Delivery System

Community Involvement

Health systems
HS boundaries: Activities in relation to health actions: activities with indirect impact are to be excluded (investments on water supply and sanitation, food subsidies, supplementary school health meals, etc while water quality control and micronutrient supplementation through health care delivery system is included.

The environment
The environment in which health services are delivered includes: How resources are raised. How these are allocated between primary, secondary and tertiary levels of care, and between rural and urban areas. Who provides services (the public-private mix). Policy on community participation. Whether a health service uses a district based model or not.

Health System Model

Input Distribution

Service Output

Service Inputs

Community Participation

Service Outcome

Health Problems

A.A.Kielmann

HS Functions
(1)Stewardship, Leadership or Governance (2)Resource development:

(3)Health care financing

(4)Service delivery

(1) Stewardship, Leadership or Governance?

Stewardship
Careful and responsible management of the well-being of the population
WHR 2000

Leadership
The art or process of influencing people so that they will strive willingly and enthusiastically towards the achievement of the group's mission.

Governance
The act of affecting government and monitoring (through policy) the long-term strategy and direction of an organization. It generally comprises the traditions, institutions and processes that determine how power is exercised, how citizens are given a voice, and how decisions are made on issues of public concern.

(2) HS functions: Resource development

- human resources for health - knowledge for health ( health research and health system research) - technology development - physical facilities

(3) HS functions: Health care financing:

-analysis & development of HCF options - resource mobilization - pooling of financial resources - purchasing of services - monitoring & evaluation of HCF

(4) HS functions: Service delivery:

- Level of organization of health service delivery system (PHC, 2ry and 3ry care) - management of public-private mix - quality assurance & improvement - accreditation systems

HS goals
To improve health and to reduce health inequalities To secure fairness of financial contribution ( equity concerns) To be responsive to users non medical needs

WHO Health System Conceptual Framework: WHR 2000

Health System Functions Health System Objectives

Stewardship (Oversight)

Responsiveness (to peoples non-medical expectations)

Delivering Services (Provision)

Creating Resources (Investment and training)

Health

Financing (collecting, pooling, purchasing)

Fair (financial) Contribution

Contribution of health systems

Health status has improved before HS development world wide: role of social & economic determinants of health Regression analysis of 6 social determinants( Health, nutrition, education, water, housing and income has shown high correlation Difficult to isolate HS contribution Countries with similar economic status & similar social determinants of health differs on outcomes of health

Contribution of health systems

Life expectancy at birth 75 77 76 74 70 73 69 69 GNP per capita ( US $) USA 17,500 Canada 14,000 Australia 12,500 N. Zealand 7,000 Venezuela 2,900 Cuba 2,000 S. Korea 2,500 N. Korea 1,200

Contribution of health systems

Studies have shown that HS do matter:

- improved equity - increased efficiency - improved responsiveness : population satisfaction

Health outcomes are related to the HS development : need to invest in HSD Importance of HS performance assessment

Conclusions
HS are important & deserve to be strengthened HS do interact with surrounding political, economic, cultural environments HS functions need to be mapped:
- assess strengths & weaknesses - improve implementation

HS goals should be monitored & evaluated Need to strengthen information support to HS Need to invest in capacity building
- health system research - policy analysis & policy dialogue

Qs, Comments????