Moving toward UHC Sudan NATIONAL I N I T I AT I V ES, KEY CHALLENGES, AND THE ROLE OF COLLABORATIVE ACTIVITIES Moving toward UHC: Sudan Sudan’s snapshot 1 Sudan’s snapshot Existing national plans and policies to achieve UHC 2 41+59+C Key challenges on the way to UHC 4 UHC Service Coverage Results of Joint External Evaluation Collaborative efforts to accelerate progress toward UHC 6 Index (SDG 3.8.1, 2015) of core capacities for pandemic preparedness (JEE, 2016) 41% References and definitions 8 Score (for capacity) # of indicators (out of 48) 5 Sustainable 4 4 Demonstrated 7 Catastrophic OOP health expenditure incidence at the 10% threshold 3 Developed 14 (SDG 3.8.2) 2 Limited 19 NO DATA 1 No capacity 4 Health results Performance of service delivery – selected indicators LMIC Maternal Mortality Under-Five Mortality (PHCPI, 2014-2015) Sudan average Ratio (WHO) Rate (WHO) Per 100,000 Live Births Per 1,000 Live Births Care-seeking for symptoms of pneumonia 48.3% 61.5% 744 Dropout rate between 1st and 3rd DTP vaccination 4.1% 7.5% 311 128 Access barriers due to 70 treatment costs NO DATA 47.4% Access barriers due to distance NO DATA 35.8% 1990 2015 1990 2015 70 (SDG target) 25 (SDG target) Treatment success rate for new TB cases 82% 80.1% Life Expectancy Wealth Differential at Birth (WHO) in Under-Five Mortality (PHCPI) Provider absence rate NO DATA 28.9% Caseload per provider NO DATA 9 64 per day 59 NO DATA Diagnostic accuracy NO DATA 47.9% More deaths in lowest than highest wealth quintile Adherence to 2000 2015 per 1,000 live births clinical guidelines NO DATA 33.6% See page 8 for References and Definitions. 1 Moving toward UHC: Sudan Moving toward UHC: Sudan Existing national plans and policies to achieve universal health coverage (UHC) SERVICE DELIVERY REFORMS HEALTH FINANCING REFORMS Sudan’s new National Health Policy details Expansion of the national health insurance several service delivery reforms. Priority areas program for the poor. Sudan has recently include: (1) strengthening the management taken steps to expand its National Health capacity of decentralized health services Insurance (NHI) program from civil servants through state and local capacity building and and formal sector employees only, to integrating vertical programs into primary care include all poor and vulnerable populations. principles; (2) improving equity in coverage Enrollment is now offered to all citizens and the quality of primary health care (PHC) under the same scheme, and coverage of through investments in facility infrastructure; vulnerable groups (pensioners, indigents) (3) strengthening the quality, safety, and is subsidized by public funds. As a result, efficiency of secondary and tertiary services; insurance coverage is reported to have and (4) strengthening efficient ambulatory increased rapidly in the past two years. The systems and emergency medical care through government has also recently implemented the development and implementation of referral a free maternal and child health medicines systems and guidelines, as well as strengthening program for all. Coverage with free medicines emergency care and triage systems. for children under 5 has increased; however, the availability of free pregnancy-related Increasing access to care and service coverage. medicines remains low. The 2016 NHI law Sudan has recently committed to moving away also attempts to address other challenges: from a hospital centric delivery system to moving toward national pooling, introducing increase PHC coverage, especially for the poor. a split between provider and purchaser The scope of services offered has expanded, functions, and initiating strategic purchasing. resulting in coverage for certain chronic conditions. The government also supports the GOVERNANCE REFORMS implementation of a family health approach, Federal leadership. In recent years, the which started in five states with the deployment Federal Ministry of Health (FMOH) has led of family physicians with master’s degrees. efforts to strengthen the planning process Community health workers are also trained and under the Ministry’s leadership and to the National Health Sector Coordination the effectiveness of their participation, and deployed, to increase outreach to communities improve harmonization of donors’ plans Council (NHSCC) was created, chaired by the maximize outcomes. and support the utilization of health services. with country priorities. At the highest level, President of the Republic, with membership from federal ministers, state governments, and National Health Strategy. Substantial progress other government entities. The FMOH acts as was made in 2016 to define a coherent health Secretariat of the Council, to govern the health sector strategic plan with a defined policy sector and promote inter-sectoral coordination. direction, measurable targets, and estimated A network of civil society organizations costs, based on policy dialogues across different working in health was developed to harmonize sectors. Mechanisms to strengthen coordination efforts with health sector priorities, improve and improve transparency were also established. 2 3 Moving toward UHC: Sudan Moving toward UHC: Sudan Key challenges on the way to UHC WEAKNESSES AND BOTTLENECKS negatively affect the efficiency of the system. IN SERVICE DELIVERY Lines of responsibility need to be clarified. Coverage of essential health services. Many health facilities face shortages of staff, Although Sudan has not met the health-related absenteeism, drug stock-outs, and limited Millennium Development Goals (MDGs), several staff performance. key health indicators have improved. Child efforts to increase free and subsidized care co-payments, and claims reimbursements. mortality has decreased, DPT3 immunization Pandemic preparedness. A 2016 Joint External for vulnerable populations. Spending is Overall, health facilities are challenged in coverage has increased, and a large majority of Evaluation (JEE) of International Health skewed toward curative services and does mobilizing adequate financing for their women now deliver in the care of a skilled birth Regulations (IHR) core capacities identified not prioritize PHC. functioning. attendant. However, challenges remain with a wide range in terms of Sudan’s pandemic health results in Sudan below the average of preparedness, with areas where systems are Major financial protection schemes. The GOVERNANCE CHALLENGES comparable countries. Neonatal mortality has already established and sustainable to areas National Health Insurance Fund (NHIF) Institutional challenges. While leadership stagnated and child undernutrition remains a where currently no capacity exists at all. Sudan covered 43.8% of the Sudanese population at for the development of policies and strategies serious issue. The high fertility rate is coupled has sustainable capacity in the following the end of 2016 (nhif.gov.sd), and premiums for is strong, this does not always translate into with an unmet need for contraceptives, low aspects: national vaccine access and delivery, households living below the poverty line were action. Efforts to decrease verticalization and institutional delivery, and high maternal linking of public health and security authorities covered by public funds. While significantly fragmentation must continue, supported by mortality. In spite of recent investments, it is during a biological event, and systems in expanding coverage, the efficiency of health the policies of integration adopted as part of estimated that many people lack geographic place for sending and receiving medical financing is impeded by fragmented pools, the 2012–2016 health strategy. Furthermore, access to a health facility, with significant countermeasures and health personnel during especially those of the FMOH and NHIF and the horizontal knowledge sharing mechanisms disparities between states. Most PHC facilities a public health emergency. Future capacity overall lack of coordination and management and coordination require strengthening, cannot provide the five essential components development is needed for: antimicrobial capacity. Social security taxes, such as the Zakat despite recent progress from inter-sectoral of a PHC package (reproductive health, resistance detection, antimicrobial stewardship Fund, subsidize the health care costs of lower groups (i.e., committees, task forces, steering immunization, nutrition, prevention and activities, an electronic real-time reporting income groups by higher income groups. The groups) and the establishment of the new treatment of common diseases, and essential system that is interoperable and interconnected, free care for the under-five initiative incentivizes structure of partnership forums. drugs). Access to basic health services is and functioning mechanisms for detecting and the utilization of health services. constrained, especially in rural areas where the responding to chemical events or emergencies. Decentralization. The health system in majority of the Sudanese population live. Challenges of fragmented financing. Health Sudan is decentralized, with three levels of THE STATE OF HEALTH FINANCING facilities receive funds from different sources, governance: federal, state, and local. Health Quality of care. Investments in primary care Overall funding for health. Sudan spends each with distinct accountability mechanisms care provision is devolved to the 18 states, are insufficient and the referral system is just over 5% of its GDP on health, with private and incentive structures. External financing with a significant share of the federal health not always functional. Additional challenges spending as the largest source for health is managed by the FMOH and used to finance consolidated budget transferred through include a lack of specialized staff trained in spending. Out-of-pocket payments represented vertical programs such as tuberculosis, malaria, federal block grants. However, the law that management, human resources, and finance 75.5% of total health expenditure in 2014 (WHO and HIV. Staff salaries are managed by the delegated responsibility and financing in public hospitals. Fragmentation of service Global Health Expenditure Database—GHED, state health ministries, while curative care is functions to states and localities lacks clarity. delivery between multiple providers, including 2017). One of the main challenges faced by funded by the NHIF, the Ministry of Health, In certain cases, the health sector does not the National Health Insurance Fund (NHIF), Sudan in health financing is overreliance on and the Ministry of Welfare and Social Security. always receive resources on time and in full, military, police, nongovernmental organizations these out-of-pocket payments, which creates a Recurrent spending for medical supplies (e.g., with some states noting that many payments (NGOs), universities, and the private sector, may barrier to access for the poor in spite of recent on drugs) relies on a combination of user fees, are not released to providers. 4 5 Moving toward UHC: Sudan Moving toward UHC: Sudan Collaborative efforts to accelerate progress toward UHC EXISTING INITIATIVES SUPPORTED PLANS FOR FUTURE BY EXTERNAL PARTNERS COLLABORATIVE WORK External partners are engaged in Sudan to build national capacity and strengthen the health Policy and Human Resources Development system. The effort to institutionalize monitoring (PHRD)-funded advisory support of effective development cooperation practices The joint work under the Tokyo Joint UHC among the different sector partners (government, Initiative includes activities to identify priorities development partners, civil society organisations for initial work, on which to build future efforts. (CSOs), and the private sector) was initiated PHRD-funded activities aim to improve the by the IHP+ 2016 monitoring round, where delivery of a package of services that integrate three-fourths of the development partners signed the delivery of nutrition services, strengthen the local compact. Governments became country capacity for pandemic preparedness, the principal recipient for health system and support health workforce development. It is support from the Global Fund, with further expected that the findings of analytical work by plans to strengthen collaboration through PHRD will contribute to further collaborations the government system. toward improving the entire health system. The Tokyo Joint UHC Initiative, supported by Additional planned PHRD-supported activities the government of Japan and led by the World include knowledge exchange activities and Bank (WB), in collaboration with the Japan workshops on health financing, diagnostic International Cooperation Agency (JICA), the studies on provider payment mechanisms, United Nations Children’s Fund (UNICEF), and public financial management, and primary the World Health Organization (WHO), and the health care self-assessment. Bringing successful UHC partnership, led by WHO and supported experiences from other countries for integrating by the European Commission and Luxembourg, nutrition in the delivery of health services in are supporting the government of Sudan and Sudan is also a planned activity. Furthermore, strive to accelerate progress toward UHC. This the Tokyo Joint UHC Initiative will closely support will enable nationally-led strategic cooperate with other investments in health, health system strengthening to achieve UHC, as such as those by the Global Fund and Gavi, to well as pandemic preparedness. contribute to health system strengthening. Considering that other sectors, such as nutrition and water and sanitation compose the foundations of heath for all, challenges in these fields also will be considered under the joint work. 6 7 Moving toward UHC: Sudan References & Definitions (page 1 indicators) UHC Service Coverage Index (2015) – Life Expectancy at Birth (2000-2015), WHO/World Bank index that combines 16 Maternal Mortality Ratio (1990-2015), tracer indicators into a single, composite Under-five Mortality Rate (1990-2015) – metric of the coverage of essential health WHO Global Health Observatory: services. For more information: WHO/World http://apps.who.int/gho/data/node.home Bank (2017). Tracking UHC: Second Global Monitoring Report. Wealth Differential in Under-five Mortality (Single data point, year varies by country) Catastrophic out-of-pocket (OOP) health – Indicator used by the Primary Health Care expenditure incidence at the 10% threshold Performance Initiative (PHCPI) to reflect equity (Single data point, year varies by country) – in health outcomes. For more information: WHO/World Bank data from Tracking UHC: https://phcperformanceinitiative.org/indicator/ Second Global Monitoring Report (2017). equity-under-five-mortality-wealth-differential Catastrophic expenditure defined as annual household health expenditures greater than Performance of service delivery – selected 10% of annual household total expenditures. indicators (Single data points, years vary by country) – Indicators used by the Primary Health Results of the Joint External Evaluation of Care Performance Initiative (PHCPI) to capture core capacities for pandemic preparedness various aspects of service delivery performance. (2016/17, year varies by country) – A voluntary, PHCPI synthesizes new and existing data from collaborative assessment of capacities to validated and internationally comparable prevent, detect, and respond to public health sources. For definitions of individual indicators: threats under the International Health https://phcperformanceinitiative.org/about-us/ Regulations (2005) and the Global Health our-indicators#/ Security Agenda. 48 indicators of pandemic preparedness are scored using five levels (1 is no capacity, 5 is sustainable capacity). https://www.ghsagenda.org/assessments Photo Credits Page 3 & 5: Salahaldeen Nadir / World Bank Page 7: Arne Hoel / World Bank Co-authored by: 8