Several challenges were highlighted by study participants. The key challenges confronting implementation that have significant impact on the performance of the function are discussed in this section.
a) Lack of coordination in developing health plans
Unlike other ministries in Sudan, there is good coordination between SMOH and FMOH even though SMOHs are not legally committed to FMOH on the administration level as the technical and financial support from FMOH to SMOH contribute significantly to
strengthening the collaboration. Nevertheless, there is a notable variation in the level of the collaboration among the states which has potentially negative consequences particularly in the health planning commitments. For example, where some states did not submit the state health plan before the planning meetings the FMOH couldn’t consider their actual needs in the national health plans and also reflect these in the implementation phase of the activities of the health plan. However, in critical cases, the FMOH escalates problems to the prime
minister or Sudanese president. Responses from decision-makers appeared to reflect a theory- practice gap, with some arguing that co-ordination is very clear, while others questioned its practical operation. For example, one argued:
‘There is an annual meeting to discuss the final version of the ministries’ plans before getting the approval. In this meeting, everyone knows what other is doing in all ministries; thus there is a complete sort of coordination with respect to the activities of all health plans and all people know about each other work.’
While another was more sceptical:
‘Coordination in the vertical level between FMOH and other ministries is a significant challenge. Convincing other federal ministries is too difficult a job as every federal ministry prefers to work within its mandate and do not prefer to collaborate with us in health projects according to our supervision since these projects are health projects initiated by us’
b) Insufficient and lack of data accuracy
The majority of decision makers and stakeholders participants highlighted insufficient and unreliable data as a major obstacle in developing and monitoring the health plans. One decision maker mentioned, for example:
Surveys couldn’t provide comprehensive information needed in order to design the plans… It is difficult to ensure whether a particular village has a VMW or not and also the exact number of VMW in these communities. There is no registration system that can inform FMOH about the availability of VMW and their distribution across the local authorities
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Another decision maker said:
‘Still you can read besides some objectives in our health plans the statements like ‘to be determined’….and ‘the indicator will be increased by 10 %’ … of course without knowing the current level of it (the baseline)… in order to design a good plan, it should be evidence-passed plan, we are trying to implement this approach but the lack of information is a long-lasting problem...’
Additionally, the FMOH picture of the entire health projects running in the states is limited by the degree to which these are run by NGOs, particularly those that NGOs implemented directly with SMOH. That has negative impact on the planning process and budget allocation management.
c) Unrealistic targets
As a result of the above problems, there is a lack of information on which to base targets. A decision maker said:
‘Always keep saying in the planning meetings … “we can do it” as if a miracle will occur … these targets indeed are
beyond their capacity ... very optimistic and unrealistic; thus they fail always to achieve targets although they accomplish
them partially… also, there is another associated problem
which is they cannot judge precisely the time needed for
activities; thus always they put unrealistic time plans’
Furthermore, the data of health services provided by non-ministries of health (i.e., military, police, university hospitals sector, health insurance, and private sectors) are not available to FMOH. That constitutes a serious obstacle in developing health plans particularly as these sectors represent about 10% of health service provision in Sudan. As mentioned previously this challenge is related to the very weak collaboration between these sectors.
d) ‘Brain Drain’ and poor capacity of the Staff:
Almost all interviewees addressed the problem of the high rate of turnover among qualified staff at FMOH, which severely affects the workflow of all parts of the health system. Generally, FMOH recruits people with long experience and a good level of education. However, well-qualified people, particularly physicians and middle career staff, receive better offers from international organisations or other countries; which has a particularly severe impact on health service provision.
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A decision maker mentioned:
‘The high turnover occurring among middle career level causes a serious problem particularly we do not have a good institutional archiving system in FMOH and SMOHs; thus a lot of important documents have been lost... we train people and as soon as they become well qualified they leave us to different well paid jobs’
Additionally, a stakeholder raised another important disadvantage of the high turnover:
‘This year we did not get any contribution from the focal
point of the FMOH because he left the ministry before
completing the discussion and there was not replacement’
Also…
‘In order to proceed the activities and transfer the money on time we need to receive their progress reports but due to the high level of turnover and lack of institutional memory, there is always delay in receiving these reports thus delaying in transferring money to the ministries.. Sometimes because of
this delay, money goes back to the main office’
This particular challenge is discussed further in chapter 9, in presenting the challenges facing the human resource for health.
e) Lack of institutional memory and health information system:
The majority of decision makers and stakeholders addressed the issue of lack of institutional memory as knowledge still exists outside the formal records systems and archives;
alternatively, staff rely on their own memories; thus recall problems and moving staff from one position to another or turnover are affecting severely the flow of the work and losing important documents and data. This compounds the impact of high staff turnover. Similarly occurring with health information system, as there is severe shortage in the information system although there are many initiatives such as health observatory and a lot of effort has been exerted in collecting data in several health aspects; yet the data are not complete or accurate.
f) Financing of health system
There are many obstacles under the financing challenges, which affect not only the health plan procedure and performing the activities but all parts of the health system, (see section 8.2 for further details).
g) Donors’ interests
Many challenges have been encountered in the health system in relation to the heavy reliance on donor aid. Donors have not aligned their plans with the national/state health plans and
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addressing the actual health needs because most of them direct the budgets according to their own mandates regardless of the needs or activities identified in the health plan. Therefore, various national needs like establishing new health facilities, improving midwifery training programmes, working in particular regions or running certain maternal health activities or renovating ones cannot be done using the donor aid.
Consequently, maternal health needs and setting the priorities are guided by donors’ interests. Similarly, the health plans have been controlled also by donors’ visions rather than a national one. All these aspects lead the health plan to be a fragmented plan which lacks clear and integrated objectives.
One decision maker mentioned strategies through which goals could be aligned with system planning in some degree:
‘Donors are fixable to some extent. That is, if they propose to finance particular activities in a particular state and there is no need to run these activities in this state, we can agree with them to change the state or change the activities but in the same field. For example, a particular UN-donor wanted to train village midwives and we did not need to conduct more training in this area we suggested to train health visitors and they accepted to do that. ...
We have budgeted road map since 2009. We ask donors that wanted to work in reproductive health arena to select activities from the plan... the things are now becoming more organised and clearer than before’
A donor stakeholder mentioned:
We do not impose our perspective on FMOH and vice versa... it is a consultative process ... they know our limited budget and the organisation’s regulations and our mandate… also they agreed upon the states that we selected to work in’