CHALLENGES OF HEALTH SYSTEM IN CHALLENGES OF HEALTH SYSTEM IN SUDAN:SUDAN:

BALANCE PRIVATE/PUBLIC:BALANCE PRIVATE/PUBLIC:THE WAY AHEADTHE WAY AHEAD

MUSTAFA KHOGALI MUSTAFA KHOGALI JUNE 2012JUNE 2012

OUTLINEOUTLINE

1.1. Role of Health SystemsRole of Health Systems

2.2. Health Status /Republic of Sudan (RS)Health Status /Republic of Sudan (RS)

3.3. Status of Private Medical Sector since 1990Status of Private Medical Sector since 1990

4.4. Major Health Challenges: Major Health Challenges:

Public / Private Overlap (Dual Practice)Public / Private Overlap (Dual Practice)

5.5. The Way AheadThe Way Ahead

6.6. Conclusion Conclusion

ARAB COUNTRIESARAB COUNTRIES(Map)(Map)

POLITICAL MAP OF REPUBLIC OF POLITICAL MAP OF REPUBLIC OF SUDANSUDAN

HEALTH SYSTEMHEALTH SYSTEM

Comprising of all organizations, institutions Comprising of all organizations, institutions and resources that are devoted to produce and resources that are devoted to produce health actions.health actions.

Objectives:Objectives:

Improving H. of PopnImproving H. of Popn

Responding to people expectationsResponding to people expectations

Providing financial protection against the Providing financial protection against the cost of ill health.cost of ill health.

MAJOR HEALTH CHALLNGESMAJOR HEALTH CHALLNGES

A A

Chronic Diseases Chronic Diseases

Emerging Diseases Emerging Diseases

Infectious/Endemic Diseases Infectious/Endemic Diseases

B B

H. Systems H. Systems

H. Services Delivery H. Services Delivery

Human Resources in Health Human Resources in Health

Public spending on health -DISPARITY Public spending on health -DISPARITY

HEALTH SYSTEMS DEVELOPMENT WORLDWIDEHEALTH SYSTEMS DEVELOPMENT WORLDWIDE

- 1920 1920 Founding of Nat.H. Care Systems Founding of Nat.H. Care Systems

- 1970-80 – Promotion of PHC as a route to achieve universal 1970-80 – Promotion of PHC as a route to achieve universal

coverage. (Success in Developed Countries)coverage. (Success in Developed Countries)

- 1990 1990 More concerned with Demand. More concerned with Demand.

New Universalism. High Quality Delivery of Essential Care.New Universalism. High Quality Delivery of Essential Care.

HUMAN RESOURCE FOR HEALTH (HRH)HUMAN RESOURCE FOR HEALTH (HRH)

HRH policies ---------- > improve HS performance HRH policies ---------- > improve HS performance

HRH involved with both resource generation / service provision HRH involved with both resource generation / service provision functionfunction

It is crucial It is crucial

Issues:Issues: Education of Health ProfessionalsEducation of Health Professionals Imbalance in workforceImbalance in workforce MigrationMigration Working conditionsWorking conditions

HEALTH CARE SERVICESHEALTH CARE SERVICES

Services depend on Health Care Workers Services depend on Health Care Workers

Community SatisfactionCommunity Satisfaction

HISTORY OF HEALTH CARE IN SUDANHISTORY OF HEALTH CARE IN SUDAN

1899 Army1899 Army

1904 Medical Department of N. Sudan1904 Medical Department of N. Sudan

1905 Central Sanitary Board 1905 Central Sanitary Board

1924 S M Services / Kitchener S M.1924 S M Services / Kitchener S M.

1924 (HWF: 16 British Doctors, 30 1924 (HWF: 16 British Doctors, 30 Syrian Doctors and 20 Sudanese Medical Syrian Doctors and 20 Sudanese Medical Assistants )Assistants )

HISTORY OF HEALTH CARE IN SUDANHISTORY OF HEALTH CARE IN SUDAN

1951 Local Government Act.1951 Local Government Act.

1960 Province Administrative Act.1960 Province Administrative Act.

1971 Popular Governance Rule. 1971 Popular Governance Rule.

1979 Authorities' of M of H (Provinces). 1979 Authorities' of M of H (Provinces).

1980 Local Govt. Act (5 reg.ex KH)1980 Local Govt. Act (5 reg.ex KH)

1991 Adoption of Federal System.1991 Adoption of Federal System.

Population by Region/Hospitals/BedsPopulation by Region/Hospitals/Beds(CBS 2011)(CBS 2011)

Region Pop000 % P/Hos Beds %Region Pop000 % P/Hos Beds %

Khart. 5274 17 46 6546 26Khart. 5274 17 46 6546 26

Cen(G/WN) 5306 17 87 3856 15Cen(G/WN) 5306 17 87 3856 15

North(RN/N) 1819 06 29 2095 08North(RN/N) 1819 06 29 2095 08

E(RS/K/G) 4534 15 57 3353 13E(RS/K/G) 4534 15 57 3353 13

SE(Sen/BN) 2117 07 50 3491 14SE(Sen/BN) 2117 07 50 3491 14

SW(NK/Sk) 4327 14 44 3133 13SW(NK/Sk) 4327 14 44 3133 13

Darf(N/S/W) 7516 24 32 2529 10Darf(N/S/W) 7516 24 32 2529 10

SOC/ECON. INDICATORSSOC/ECON. INDICATORS

Variable SDG(M) % Variable SDG(M) %

1-G D P 1257571-G D P 125757

2-Total Exp. H 9203 7.32-Total Exp. H 9203 7.3

3- Govt. Exp. H 2525 2.0 3- Govt. Exp. H 2525 2.0

4-Priv. Exp. H 6678 5.34-Priv. Exp. H 6678 5.3

5-Out /Pocket Exp 6422 96.05-Out /Pocket Exp 6422 96.0

Per cap Exp = 2/Pop =297SDG =60 $ Per cap Exp = 2/Pop =297SDG =60 $

Current Numbers of Doctors In RS 2010Current Numbers of Doctors In RS 2010

Housemen General Practitioners Registrars Specialist

Ministry Others* Ministry Others* Ministry Others* Ministry Others* Total

3653 0 4113 50 1794 0 1586 526 11722

* Others Refer to categories registered in other than ministry e.g. private facilities source (FMOH, 2010)

PRIVATEPRIVATE HEALTH CARE SYSTEM / MEDICAL HEALTH CARE SYSTEM / MEDICAL EDUCATIONEDUCATION

Until 1990 5 Private HospitalsUntil 1990 5 Private Hospitals

4 Medical Schools (Khartoum1924, Gezira 4 Medical Schools (Khartoum1924, Gezira 1979, AUW 1990, Omdurman Islamia 1990).1979, AUW 1990, Omdurman Islamia 1990).

2011 Private Hospitals and 2011 Private Hospitals and

Diagnostic Centers: 190Diagnostic Centers: 190

Khartoum State: 102Khartoum State: 102

PRIVATE HEALTH CARE SYSTEM / MEDICAL PRIVATE HEALTH CARE SYSTEM / MEDICAL EDUCATIONEDUCATION

Medical Schools: 32Medical Schools: 32

Khartoum: 19Khartoum: 19

(Private 14 and Governmental 5)(Private 14 and Governmental 5)

All other States: 13All other States: 13

LIST OF MEDICAL SCHOOLS (KH. STATE)LIST OF MEDICAL SCHOOLS (KH. STATE)

PrivatePrivate

1.1. Ahfad 8. ALWataniaAhfad 8. ALWatania

2.2. Karari 9. ALRibat Karari 9. ALRibat

3.3. Af AlAlamia 10. Sud. I. U. Af AlAlamia 10. Sud. I. U.

4.4. U. Tech. 11. ALNeelU. Tech. 11. ALNeel

5. UMST 12. ALMogtarbeen5. UMST 12. ALMogtarbeen

6. K M S 13. ALYarmouk 6. K M S 13. ALYarmouk

7. ALRazi 14.Om ALAhia7. ALRazi 14.Om ALAhia

LIST OF MEDICAL SCHOOLS (KH. STATE)LIST OF MEDICAL SCHOOLS (KH. STATE)

GovernmentalGovernmental

1.1. KhartoumKhartoum

2.2. Alzeem AlAzharyAlzeem AlAzhary

3.3. Omdurman IslamiaOmdurman Islamia

4.4. AlNeeleenAlNeeleen

5.5. BahriBahri

STATESTATE MEDICAL SCHOOLSMEDICAL SCHOOLS

1.1. ALGazera 1979ALGazera 1979

2.2. Kassala 1991Kassala 1991

3.3. Kordofan 1991Kordofan 1991

4.4. AlFasher 1991AlFasher 1991

5.5. Shandi 1994Shandi 1994

6.6. ALImam ALHadi 1995ALImam ALHadi 1995

7.7. Bakhat ALRuda 1997Bakhat ALRuda 1997

8.8. ELGedaref 1997ELGedaref 1997

STATE MEDICAL SCHOOLSSTATE MEDICAL SCHOOLS

9. Dongola 19979. Dongola 1997

10.Sennar 199710.Sennar 1997

11. Wadi ALNeel 199811. Wadi ALNeel 1998

12. West Kordofan 200712. West Kordofan 2007

13. Red Sea 200713. Red Sea 2007

HISTORICAL PROSPECTIVE OF PRIVATE HISTORICAL PROSPECTIVE OF PRIVATE PRACTICE SINCE 1990PRACTICE SINCE 1990

1.1. 1991 Users Fees for P H Facilities.1991 Users Fees for P H Facilities.

2.2. 1992 Macroeconomic Reforms ↓ Govt. 1992 Macroeconomic Reforms ↓ Govt. expenditure. expenditure.

3.3. 1994 Adoption of 26 States.1994 Adoption of 26 States.

4.4. 1994 Social Health Insurance1994 Social Health Insurance

5.5. 1998 Local Governmental Act (633 1998 Local Governmental Act (633 localities) and its impact on H Services. localities) and its impact on H Services.

HISTORICAL PROSPECTIVE OF PRIVATE HISTORICAL PROSPECTIVE OF PRIVATE PRACTICE SINCE 1990PRACTICE SINCE 1990

6. 2003 New Local Government Act (134 6. 2003 New Local Government Act (134 localities).localities).

7. 2005 Restructuring Health System into 7. 2005 Restructuring Health System into three levels (Federal/ State/ Locality).three levels (Federal/ State/ Locality).

8. Comprehensive Peace Agreement 8. Comprehensive Peace Agreement

PUBLIC/ PRIVATE OVERLAPPUBLIC/ PRIVATE OVERLAP

P. Prov.P. Prov. Capture a significant share of H Capture a significant share of H services delivery.services delivery.

Dual Practice Dual Practice : Combination of public : Combination of public sector Clinical work / Private Approach.sector Clinical work / Private Approach.

(1) Conceptual (2) Descriptive(1) Conceptual (2) Descriptive

(3) Impact on H Care System/ H Status. (3) Impact on H Care System/ H Status.

(4) Qualitative (5) Possible Interventions(4) Qualitative (5) Possible Interventions

PUBLIC/ PRIVATE OVERLAPPUBLIC/ PRIVATE OVERLAP

Dual Practice: Dual Practice: Multiple health – related Multiple health – related practices in the same or different sites.practices in the same or different sites.

Public / PublicPublic / Public

Public / Private Private / Private Public / Private Private / Private

It is worldwide spreadIt is worldwide spread

Most Prominent in Developing CountriesMost Prominent in Developing Countries

IMPACT OF DUAL PRACTICE IMPACT OF DUAL PRACTICE

1.1. Predatory Behaviour: Predatory Behaviour: e.g. C S rates e.g. C S rates (46% Private, 16% Public) and MRI etc.(46% Private, 16% Public) and MRI etc.

2.2. Conflict of Interest Conflict of Interest

3.3. Internal Brain Drain (Rural → Urban) Internal Brain Drain (Rural → Urban) Public to Private .Public to Private .

4.4. Competition For TimeCompetition For Time

5.5. Corruption in the health Sector /Corruption in the health Sector /

Outflow of ResourcesOutflow of Resources

POSSIBLE INTERVENTIONSPOSSIBLE INTERVENTIONS

1. Total Banning of DP1. Total Banning of DP

2.DP with restrictions.2.DP with restrictions.

3.DP without restrictions3.DP without restrictions

WHAT TO DO??WHAT TO DO??

1.Addressing the DP problem openly.1.Addressing the DP problem openly.

2.Improving working conditions.2.Improving working conditions.

3.Incentives.3.Incentives.

4.Professional Value System4.Professional Value System

5.Peer Pressure.5.Peer Pressure.

6.Pressure from Users.6.Pressure from Users.

7.Recruitment Practice.7.Recruitment Practice.

8.Regulating Private Practice.8.Regulating Private Practice.

CONDITIONS OF SUCCESSCONDITIONS OF SUCCESS

Strong leadership at both governmental and syndicate levels.Strong leadership at both governmental and syndicate levels.

A PC structure at the national level.A PC structure at the national level.

A national authority committed to PC:A national authority committed to PC:

- Maintains focus on the vision through the organization- Maintains focus on the vision through the organization

- Manages the change process and adapts to the local dynamics- Manages the change process and adapts to the local dynamics

- Creates professional incentives on merit and performance.- Creates professional incentives on merit and performance.

- Enforce Regulations equitably- Enforce Regulations equitably

Flexibility from professional associations and health insurance. Flexibility from professional associations and health insurance.

CONCLUSIONCONCLUSION

The tremendous variety of approaches to various The tremendous variety of approaches to various aspects of DP throughout the World provides an aspects of DP throughout the World provides an opportunity for each nation to identify opportunity for each nation to identify ALTERNATIVESALTERNATIVES suitable for its prevailing condition suitable for its prevailing condition & current operations.& current operations.

Each country should take Each country should take ADVANTAGEADVANTAGE of of knowledge derived from already existing knowledge derived from already existing experiences in other countries. experiences in other countries.

HOPEFULLY SO ?!HOPEFULLY SO ?!