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!