Free healthcare policy
for under-fives and
pregnant women in
northern Sudan:
findings of a review
Dr Sophie Witter on behalf of FMoH team
March 2011
Research team
Key informant interviews
 Khalda Khalid
 Rania Hussein
 Sally Hassan Gassim
 Elsadig Eltigani
 Fatima Elzahra Ismail
Costing team:
 Mohammed Saed
 Fatima Abderhamn
 Mohamed Yahia
 Ahmed Khalil
 Khadiga Mohamed Bader
Facility survey/exit interviews
 Hiba Nasser Eldain
 Asrar Faddul Elsied
 Afraa Hamid
 Isra Abdemagid
 Dr Manarr Abdelrahman,
University of Khartoum
Background to policy
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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 underfives announced by President, January 2008
Some background on health
indicators
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Selected health indicators, 2007, Sudan
IMR
99/1,000
MMR
595/100,000
Facility delivery rate
CS rate
22%
5.60%
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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
Study objectives
To understand and advise on:
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The content and cost of the package of care
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The flow of funds from federal to states level
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How the policy is managed and monitored
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The impact of the policy
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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 tools
1.
2.
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4.
5.
key informant interviews (214)
exit interviews (138 women; 248 <5s)
facility survey (30)
costing of package (24)
secondary data and literature
Focal states: Khartoum, Red Sea, Kassala,
Blue Nile, South Kordofan
Study period: Jan-September 2010
Study limitations
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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
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Not clearly specified – no detailed written
guidelines
Very varied implementation
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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
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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?
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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?
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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
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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
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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?
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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
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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 care
Need 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
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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)
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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!