Decision makers were asked about the most effective policies or ministerial decrees in improving maternal health in Sudan. The majority mentioned several policies and decrees. Two principal actions were perceived as very powerful in reducing maternal mortality levels: The National Road Map for Accelerating the Attainment of the Millennium Development Goals (MDGs) Related to Maternal and Newborn Health and its associated costed
implementation action plan as well as the presidential decree of providing ANC and caesarean section delivery for free of charge in 2009. The decree was issued after a study reported that a large number of women cannot pay for caesarean section, thus women wait until their conditions become an emergency in order to benefit from the emergency service.
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Unfortunately, despite the importance of these two policies there are notable discrepancies among states in providing these two services for free of charge due to insufficient funds allocated to these services.
Another potentially effective strategy is the National Health Insurance system although it covered less than 37% of families on the national level by the end of 2012 (mainly covered people who are working in the formal sector or their families) according to the national statistical report. The coverage is slowly expanding year by year due to financing obstacles. In 2010 there was a decree to establish the surveillance system of maternal mortality in all states. The majority of the DM group regarded it as very helpful in identifying the causes of maternal deaths although a few mentioned that the people who are responsible for conducting the verbal autopsy are not very qualified to detect precisely the main reasons for death; therefore the usefulness of the reports is questionable, particularly since they do not cover all maternal deaths across the country; consequently the ministry is not highly dependent on these monthly reports.
During the data collection of my project, there was a decree, issued in late 2012, initiating a new national project for Expansion of Primary Healthcare. This aimed to cover Sudan entirely with a basic package of primary health care, which includes ANC, child growth monitoring, child immunisation and provision of an essential drugs list that treats the common diseases in Sudan. This project is a very promising project, particularly as the parliament allocated the budget of this project.
Also, another recent decree mentioned by many decision makers as a potentially effective decree that has been taken by FMOH in order to enhance the midwifery services through introducing a new 2-year midwifery training programme. However, many decision makers reported that this programme has been facing a serious obstacle during the implementation where the admission of the programme requires women with secondary education, which are rarely found, particularly in remote areas. Even though educated women are identified, most of them prefer to continue their studies in the university rather than enrol in a 2-year
midwifery programme, as having a midwifery certificate does not guarantee a well-paid job in the health system in Sudan. Another challenge facing application of this initiative is a severe lack of village midwives, particularly in remote areas, since the 2- year programme will delay village midwives’ graduation as compared with the current one-year programme. Also, inevitable financial obstacles associated with the expansion of the programme were highlighted by the majority of decision makers. One commented:
‘Although there are many decrees and policies issued to reduce maternal mortality and enhance maternal health in Sudan, they have not been implemented properly because there are not enough resources to maintain continuous implementation. Also, other facilities are insufficient to support like inadequate facilities, poor equipment and labs, and no proper referral system as well as the
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insufficient number and quality of health workforce. Unfortunately, we do not have all of that.’
Decision makers also identified a continuing barrier of lack of awareness of the key role of maternal health care in public health overall:
‘We need to increase the awareness of the importance of maternal health services and primary health care among the population in order to maximise the benefit of these decrees ... community leaders and ministries of health should take the lead in organising health awareness campaigns.’
To conclude, because the primary health care is largely funded by external aid, most of the primary health activities and identifying the places where the activities will be implemented are controlled by donors, particularly the multilateral donors as the major donors.
Unfortunately, there is a weak coordination among them and between the donors and ministries of health. That inevitably has a negative influence on the management regime of primary health care and eventually on the maternal health outcome, poor responsiveness level among women, and the clear mal-distribution of resources and maternal health services provision.
Indeed, many decision makers emphasised the importance of guiding the primary healthcare plan by the national vision and national policy rather than disputed among many cooperated donors mange the plan according to their views which at the end to the very poor health outcomes and malfunction in the health system. The road map of maternal mortality reduction is considered a good base to lead the PHC planning.
Accordingly, almost all decision makers know very well the rules of health planning;
however due to the challenges particularly the four main challenges: data, capacity, and poor coordination as well as imposing donors’ interests, there are critical drawbacks in designing and implementing the health plans.