Sudan

Sudan: Secondary health care facilities in emergencies - The Darfur experience

Situation analysis

Before the start of the conflict in Greater Darfur at the end of 2003, the health system had operated through self-funded mechanisms and cost-recovering tools. Traditional healers, midwifes and other medical assistants had been the main health care providers for the last 25 years. Most staff working at the health facilities was graduated at local universities (e.g. El Fasher).

The region had not received any considerable support since 1993, but for a UNDP project on the rehabilitation of Primary Health Care (PHC) centres. From the already small, normal government expenditure on health of 3 US dollar per capita per year, only a very small part was spent on Darfur.

Most health facilities were incomplete or still under construction. During the conflict, a large number of facilities was damaged or looted. Most staff had left, as salaries had not been paid since in February 2003.

A continuous lack of medical supplies, the absence of a patient transportation system and the deteriorating security situation, further illustrate the challenges encountered.

The overall infrastructure of the 29 locations that were nominated as hospitals to cover service for 7 million people in Darfur was of low quality: difficult access because of bad roads, deficient water supplies, and power sources, and poor availability of raw materials

Furthermore, the Ministry of Health at State level, under whose responsibility the health facilities in Darfur fall, did not receive sufficient support from the national or Federal level.

Physical rehabilitation

Assessment

As soon as the international humanitarian community became active in response to the Darfur crisis in May 2004, the World Health Organization (WHO) carried out a needs assessment and gap analysis for second health care facilities. According to international standards, a second health care facility has to be provided for a population of 50,000 persons within a catchment area of 50 km. The health care facility should be at least 5 km from the main road.

The assessment looked at the different options:

- whether to use the existing health facilities,

- or to set up field hospitals in IDP camps

- or to stick with mobile clinics with limited surgical capacity?

The conclusion of the assessment was that it was preferred to use the existing local facilities, as their location was already known to the local population. This also seemed the most sustainable solution for the post-conflict situation.

Selection of health facilities

The criteria for selection of state level and rural hospitals for their physical and functional rehabilitation were:

- accessibility of the facilities

- current workload and IDP movement

- potential referral network

- coverage or catchment population

The three state hospitals were nominated as priority 1a (respectively El Fasher Teaching Hospital in North Darfur, El Geneina General Hospital in West Darfur and Nyala Teaching Hospital in South Darfur).

The following key rural hospitals were then prioritized:

South:

1. Kass

2. El Dain

3. Edd El Fersan

North:

1. Kabkabiya

2. Kutum

3. Malliet

West:

1. Kulbus

2. Fur Baranga

3. Gulu

4. Zallingi

After selecting the hospitals, it had to be decided what service, and consequently what department had to be prioritized for rehabilitation.

Physical rehabilitation

As the main reasons for consultation in the hospitals were either weapon related, related to obstetric emergencies or diarrhoeal diseases and nutrition in the paediatric department, the physical rehabilitation within the hospitals were planned in three phases:

In phase I, the following areas were to be rehabilitated in order of priority:

1. triage area with capacity with minimum 20-30 beds

2. operating theatre

3. surgical ward

4. obstetric ward and delivery room

5. laboratory facility and blood bank

6. where applicable: x-ray / radiology

In phase II, the focus was on the capacity increase in the gynaecology and obstetric ward, and paediatric ward.

In phase III the rehabilitation of the medical ward and the auxiliary services such as the laundry and kitchen were addressed.

The rehabilitation can also be divided into two stages

1. the emergency stage, where very basic material was used, to rapidly initiate the process

2. the post-emergency stage, focused on more functionally adapted rehabilitation.

The selection process of the hospitals to be rehabilitated as well as the services and departments within the hospitals was performed in close coordination with all partners at state (decentralized) and federal (national) level through frequent meetings, where main issues were attended to and where activities were coordinated with the responsible agency in charge.

For sustainability at longer term, it was preferred that the service be carried out by the State Ministry of Health (SMoH). Where applicable, SMoH could be assisted by a non governmental Organization (NGO) or even WHO.

Important partners were the International Committee of the Red Cross (ICRC), Médecins Sans Frontières (MSF) and the German NGO Johanniter, and others.

WHO's role

The main activities implemented by WHO in the period between June and October of 2004 were the following:

- physical rehabilitation of the hospitals in Nyala, Kass, El Fasher, El Geneina en El Dain, Kulbus and Fur Baranga

- providing essential emergency drugs in the form of kits (Italian trauma kit + new emergency kit)

- training of local staff on:

i. trauma management and surgical skills

ii. hospital management

iii. safe blood transfusion and lab services

As of October 2004, up to today, WHO focuses on:

- The completion of the physical rehabilitation

- The introduction of the Rational Use of Drugs policy, according to the national essential drug list and according to international standards. Training of pharmacists and clinicians in this list forms an essential part of this.

- The enforcement of the referral system aims to decrease the workload by enhancing the Primary Health Care centres network and transportation facilities. A medical referral form adapted to the specific IDP situation, is to be used as a two-way communication, including the tracking of patients.

- The capacity building of the hospital management (both at federal and state level)

- Introduction or where already existing enhancement of Health Information Systems.

Health management

It needs to be emphasized that the same approach that was used in government (GoS) controlled areas in Darfur, was also applied in non-GoS areas, controlled by the Sudanese Liberation Army (SLA). This division between GoS and SLA areas was mainly an issue in the case of identification of SLA patients, in Dar Es Salaam and rural areas outside of Kutum.

Waiving of user fees

To ensure free access of the secondary health facility, the cost recovery fees had to be compensated by:

- paying incentives for the staff

- running cost of the hospital

- providing drugs and consumables

a. Incentives for the staff

In the beginning, only the key staff at the key services (the outpatient department, operating theatre and surgical ward) was paid incentives. This unfortunately had a negative impact on the overall general performance within the hospital. The policy was then modified into supporting the post or function, and not the personnel. All staff had to have the possibility to participate in the incentives system. Also, incentives could only be paid on a shift basis.

The number of posts within the second health care facility was based on Sphere standards:

- 1 nurse every 8 hours for 20 beds

- 1 doctor per 50 consultations in outpatient department

By using the hospital statistical data and the assessment report, the number of the posts could be identified

The rate of the incentives had to be estimated depending on basic salaries received from the Ministry of Health, and the current incentives scale for health workers per state.

This was taken into consideration per post, not per individual.

Incentives were only paid against a certain standard of performance and job description, and as part of the signed Technical Cooperation Agreement with the hospital.

A joint monitoring of performance was done by the medical director of the hospital and the WHO Focal Point on a daily basis. To ensure transparency, the end results of the monitoring were made available to all staff.

The revision of the process was done on a monthly basis. It was discovered that there was a need to increase the number of posts, more than the indications given by Sphere, in order to cope with the workload, especially those state and rural hospitals in migration corridors.

b. Running costs

The running costs were identified by studying the budget of the hospital and the expenditures over a minimum period of 6 months per hospital. To assure reliability of the end data, only the most reliable data were used.

The financial data were matched with the hospital statistics and the workload, taking into consideration the oscillation of conflict and population movement.

The main fields which affected the service provision for IDPs were identified such as:

- fuel for the generator,

- water supply,

- telephone calls,

- fuel for ambulance vehicles,

- stationary and printing materials such as patient files, and

- essential maintenance costs for recruitment and furniture in the hospital.

A ceiling was set for the running costs. This was the highest calculated figure supporting the particular service in relation to the percentage of increase in IDP workload.

The hospitals make requests to fund certain activities, which need to be approved by the WHO Focal Point. The money is transferred directly to the hospital bank account against a documented receipt and a report from the Focal Point.

c. Provision of drugs

According to the rational use of drugs policy, the ceiling of the amount of drugs to be received by the hospital depends on:

- IDP workload

- workload caused by the amount of emergency cases

- morbidity and mortality data on a 3-months basis