free healthcare policy for under-fives and pregnant women in northern sudan: findings of a review dr...
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Free healthcare policy for under-fives and
pregnant women in northern Sudan:
findings of a review
Dr Sophie Witter on behalf of FMoH teamMarch 2011
Research team
Key informant interviews Khalda Khalid Rania Hussein Sally Hassan Gassim Elsadig Eltigani Fatima Elzahra Ismail
Facility survey/exit interviews Hiba Nasser Eldain Asrar Faddul Elsied Afraa Hamid Isra Abdemagid Dr Manarr Abdelrahman,
University of KhartoumCosting team: Mohammed Saed Fatima Abderhamn Mohamed Yahia Ahmed Khalil Khadiga Mohamed Bader
Background to policy Free health care until 1992, then cost-sharing
introduced NHI starts in 1995 Free emergency care, 1996 Interim Constitution, 2007 – rights to basic
health care 2007 National Health Policy with focus on
MDGs and vulnerable groups Free care for pregnant women and under-
fives announced by President, January 2008
Some background on health indicators
Overall poor Some improvements
but others stagnating (e.g. MMR)
Substantial inequities (regional and by quintile)
e.g. CS: range from 0.8% in West Darfur to 14.2% in River Nile & from 1% in Q1 to 19% in Q5
Selected health indicators, 2007, Sudan
IMR 99/1,000
MMR 595/100,000
Facility delivery rate 22%
CS rate 5.60%
Study objectivesTo understand and advise on: The content and cost of the package of care The flow of funds from federal to states level How the policy is managed and monitored The impact of the policy How the free care policy is linked to drug supply
systems and to other health programmes (including other free care programmes and HI)
In addition, it sought stakeholder views on the policy, its implementation, on problems which it faces, and on proposed solutions to those problems.
Conducted by FMoH, funded in part by MDTF
Research tools1. key informant interviews (214)2. exit interviews (138 women; 248 <5s)3. facility survey (30)4. costing of package (24)5. secondary data and literature
Focal states: Khartoum, Red Sea, Kassala, Blue Nile, South Kordofan
Study period: Jan-September 2010
Study limitations
For KII, getting written reports was main challenge For facility survey, no major constraints For exit interviews, gaining adequate sample
(especially for deliveries); plus some difficult questions on expenditure
For costing, gaps in financial records Ended up having to exclude financial analysis for
two states Secondary data very fragmented and sometimes
with gaps (e.g. HMIS)
Summary of findings
Policy specification
Not clearly specified – no detailed written guidelines
Very varied implementation By kind of facilities included By services included By type of costs covered (or how much covered)
Rationing has favoured hospitals, inpatients & urban areas (e.g. RS: only 6% to HCs)
Compounded by inadequate funds and drugs
Overall expenditure
Federal funding – little addition by states or localities, except in Khartoum
In 2009, 0.58 SDG ($0.28) per person for northern states as a whole
13% of free care spending; 6% of free drugs* 1% of expenditure on health at state level (RS
+ BN) 0.005% of total public expenditure (NHA
figures)*less than a quarter of
amount to renal centre
Were resources adequate?
All KI agree on inadequacy, though estimates of gap vary (60-100%)
Hard to estimate as no unit costs established before (for budget setting) and reporting too aggregated
Using our cost estimates, the funding for 2009 would only have covered 7% of needs (assuming package = all CS and all child care)
Flow of resources
Budget-setting not well understood Resources erratic (especially cash) Drugs more reliable but still limited in quantity
and type Within states, varying approaches to
distribution – percentages, fixed amounts, according to judgement of need etc.
Partially suspended or stopped in a variety of ways in each state
Impact on utilisation
2008-9: 45% increase in child care cases; 14% normal deliveries (free care report); 24% CS
Consistent with international experiences (also facility survey and exit interviews)
Big increases in ultrasound (for deliveries) and operations (for children)
HMIS data (?quality) shows steady rise over past few years of CS by c.25% per year
But concern that two-thirds of CS elective in northern Sudan
Impact on households Exit interviews show households still paying for most items -
mean of 62 SDG per child care episode and 248 SDG per delivery
Costs unpredictable: range for CS of 54 SDG to 1,054 SDG Costs higher when add drugs to be purchased outside (61% of
drugs prescribed to women not in stock, for example) <2% totally free (both groups) 39% of households (children) and 50% (women) paid for drugs,
even though they were in stock Of household monthly spending after food, one child episode
costs 44.5% and delivery 213% on average 53% cannot afford to pay (children); 66% (women)
Health insurance and payments
29% covered in children’s exit interviews; 24% in women’s
For both groups, those with insurance paid more (though difference not significant)
More likely to say they can afford care, but still the minority (34% of insured carers of children could afford and 42% of women)
Impact on quality of care Mixed qualitative reports – concerns but no
evidence of deterioration No evidence of increase in stillbirths 51% of children >2 visits before – why? Gradient of infrastructure and staffing between
Khartoum and other states Basic equipment lacking (and sometimes worse at
higher level facilities) For women, quality is no. 1 consideration (for
children, proximity) High user satisfaction except on price and drugs
Impact on facilities Between 6% (SK) and 81% (RS) of facilities
participating in policy Context of varied rules on use of user fees Reports of increased workload (for some, not
all) Reports of debts (for some; others just
charge) Balance of revenues and expenditures over
2007-9 show improvements for most, which suggests they are coping
For staff, loss of incentives from fees (but gains from drug sales?)
Findings on drugs supply system
Drugs absorb over half of free care funds (and single biggest item of expenditure for patients too)
Supply not functioning well though: Free care adds to multiple channels CMS + RDFs not able to reliably stock essential items (often
have to buy from private sources) Facilities have to transport free care drugs Availability at facilities poor (e.g. 61% out of stock, according to
women’s EI) This was also found by facility survey – lack of even basic items,
like gloves Also higher prices at peripheral units – regressive
Linkages with health insurance Free care used as ‘first line’ in most cases –
subsidises NHI – this is also patients’ preference as avoid co-payments
But given the insufficiency of resources, NHI still bears costs, in theory
However, in practice, cash-flow issues and blocked payment channels in many areas
Plus free care is potentially disincentivising for NHI
At present, patients are still paying either way!
Monitoring of policy
Monitoring weak – no budgets for supervision, no checklists etc.
Not combining with other programmes with resources (e.g. Global Fund)
Reports varied in format, hard to analyse Very fragmented information sources; not
combined to analyse outputs, unit costs, trends, how funds used etc
Overall views of key informants
In short:
Good policy but poorly done
Many practical suggestions
for how to strengthen
RECOMMENDATIONS
Is the policy needed? Yes
Constitutional right Important to fulfil most of the objectives of the
2007 health strategy Focuses on vulnerable groups Poor health indicators and huge inequalities
(10% inst deliv Q1 vs 55% Q5, 2006 SHHS) Households bearing the brunt of costs - 67%
of total from them, according to NHA, and of this, 97% is out-of-pocket
If so, how to implement it? Option A – to continue the free care as currently designed, but
with improvements to funding, clearer guidelines and stronger monitoring and evaluation
Option B – to continue the policy as at present, but switching to a more explicit output-based system, with funds following activities
Option C – to use the health insurance system as a way of creating entitlement for free (or largely free) services for the target groups
Option D – to change the focus to providing integrated free funding at all primary facilities
Option E – other possible approaches, such as establishment of health equity funds, use of vouchers and conditional cash transfers.
Package of care
Current situation: overlapping free care policies and value-added of services unclear
Need for integration of policies to cover normal deliveries (gateway to care); emergency CS and other complications; all main children’s conditions, whether IP or OPD
Ideally for mothers, full package of ANC, delivery care, and PNC, including FP
Available at close-to-user facilities (first and second line)
The cost
Choice of approach is needed before detailed costing can be done
But the study generated broad-brush budgets for each scenario to inform debate
For A or B, cost for all deliveries and <5s care would be about 19% of the total public expenditure on health
For C, needs more detailed elaboration with NHIC For D, all care at rural hospitals and health centres
would cost in range of 10% of total public health expenditure
How to fund these? Develop clearly specified, costed package with credible
implementation mechanisms Accompanied by reforms to improve effectiveness of
sector These will include reallocating funds away from some
high-cost tertiary centres Current spend per capita is $122 ($34 from public
sources) so can afford to fund essential care, but health indicators poor and inequitable
Once improved use, then have the basis for arguing for additional pooled resources (Abuja targets (currently 6.6% of public expenditure on health, reduction in OOP etc.)
Monitoring and evaluation
Whatever option is chosen, stronger M&E is needed – we elaborate framework to include indicators on:
Coverage Cost Equity indicators Sustainability Financial protection Rational, high priority care Quality of care
Accompanying reforms which are needed….some examples
To strengthen: Drug supply system Clinical practice Primary care Strengthening NHI More transparent & fair resource allocation
Drug supply system
Study found evidence of too many parallel systems, poor availability, and high prices
Accelerate integration of 15+ national programmes and CMS/RDFs
CMS re-focussed on core role of not-for-profit supplier of essential drugs to all parts of Sudan
Operate national pricing and transport to all public facilities
In return, all debts to CMS paid off – no longer creditor of last resort
Clinical practice
Great variation across facilities in drugs and tests – often not in accordance with standards
Need for provider-friendly protocols and training
Payment mechanisms to be linked with meeting standards
Upgrading of equipment necessary too
Revitalising primary careNeed to correct bias towards hospitals (both by the
system and patients) by: freeing care/reducing financial barriers at the
primary level developing resource allocation mechanisms which
ensure more predictable funding integrated planning for infrastructure improving the drug supply to peripheral facilities motivating staff who stay in rural areas installing gate-keepers (through regulation or prices)
NHIC - recommendations
Development of actuarial analysis by the NHIC
Reform of the payment mechanisms (currently FFS)
Clear national guidelines on the payment channels for state-level NHI reimbursement of services
Investigating factors behind cash flow problems (including regularity of contributions from MoF)
What we have learned (internationally)
Confirms findings from other countries that exemptions policies targeted at vulnerable groups are often poorly specified, funded, implemented and monitored
In Sudan, the story is complicated by the federal system, the NHI, the drug supply (revolving drugs) system, the multiplicity of free care and vertical programmes, and the mixed practice on financial autonomy of public facilities
Confirms that exemptions appear simple, but are complex, as involve addressing systemic issues
Should be combined with – and may help to trigger? -wider set of health sector reforms
Shukran!