The experience of strengthenging PHC through community involvement in Western Sudan : an evaluation of the Bamako initiative base health programme in ER-Rahad Health Area .


Research type: Research Paper

Authors: Ahmed, Mohamed El Fatih A..

Abstract: The government of Sudan was committed to implementing health programmes based on the BI guidelines since the emergence of the idea in 1988. A joint MOH/UNCIEF/WHO working group in October 1988 developed a conceptual framework for implementation of nation wide health programmes. Within the BI bontext. A UNICEF review mission in 1989 suggested that a team of Sudanese experts should proceed with the programme preparation. Those preparations included a comprehensive base line survey in Greater Kordofan. In 1990 and based on the results of the survey, the team prepared 3 action plans for implementation of health programmes, based on BI guidelines in three health areas in Kordofan on pilot basis. In 1992 North Kordofan State resumed discussions with FMOH and UNICEF. The discussions culminated in launching the first BI based health programme in the country in ER Rahad H.A. Now that the programme is going on for the last four years, it was thought-that some lessons could be drawn that can be of use in improving performance in ER Rahad H.A. as well as in similar programmes in other parts of country. An evaluation comprising 5 substudies (record review, key informant interviews, focus group discussion, household survey and facility based study) was carried out to serve that purpose. The main objectives of the evaluation were to assess the accessibility, utilization and quality of health care in the H.A. Also to assess the availability and rational use of essential drugs. The financial management system and the role of the community in the management of the programme were also assessed. The study also looked into equity issues as well as other management aspects of the programme. Key observations included the following. The health services availability, quality and utilization were all tremendously improved in the first year of the programme, then started to decline. The average availability of key essential drugs for the whole H.A. was only 43.9 percent. Preventive and promotive services were seriously undrutilized. Most of the health facilities including the rural hospital lack basic laboratory, dental and ophthalmic tooks. The mamagement structure at federal levels was confined to the national BI coordinator office which is part of the PHC general directorate, the advisory and steering committee formed by the federal Health Ministry do not seem to be functioning. At state level also the steering committee did not seem to play any role in the management of the programme. The management of the programme at HA level was the sole responsibility of the HAMT. The team however did not include any community or other health related sector representatives. Management tools e.g. job descriptions, policy guidelines, written procedures, detailed plans etc. could not be found at any level. UNICEF supported the BI based programme since the preparatory stages. The role of UNICEF in ER Rahad HA programme included donation of the first drug consignment, facilitating contacts. Communications and foreign exchange arrangements for subserquent drug consignments, training and orientation workshops. The RDF component of the programme seemed to be the only actively functioning part. The selection of drugs was based on the NELD and the quantification utilized past consumtion proccdure. The system of distribution to the peripheral units apperaed to be quite inconvenient to the HWs being centralized at the HAMT HQ in town. The RDF drugs of ER Rahad HA programme officially find their way to other distribution outlets e.g other hospitals and public pharmacies in the state. The practice of HWs regarding rational prescription was quite good in the first year following the implementation of the programme. Which reflects on the quality of training. The community, however, still showed many features of irrational use of drugs. The community as community leaders, health committees or women groups were not adequaley involved in ay aspect of the programme management. Drug pricing, determination of lines of revenue expenditure and control of expenditure were all the sole responsibility of HAMT only. No geographical cultural or religious barries were existing by looking at the universal utilization of health care in the HA. The only barrier for the poor and needy in the area was the cost of service. The average monthly family expenditure on health was 1/4 - 1/3 of the total monthly family income. Users have to pay not only for drugs but also for other health services. There were no written policy guidelines regarding who will be exempted from payment, how to identity them or from where this will be compensated at any level. Exemptions were rarely if at all practiced; and even then they depended on HWs personal initiative in most cases. The main focus of the HAMT in the management of the programme was on the RDF component. The programme profits which exceeded 50 million Sudanese pounds were in the best cases used to enlarge the capital for buying more drugs. The full potential of the B1 based programme was reduced to a RDF in the minds of the community, as well as in the practice of the HAMT and the HWs in the health area..