Sudan is one of those countries which have experienced economic crisis during the period of the 1970s, and has, therefore, resorted to adopting and implementing Stabilisation and Structural Adjustment Programmes.
The significant adjustment endeavours with the IMF dates back to June 1978 and continued till 1986. In 1989, the Government of the Sudan organised the National Conference for Economic Salvation with the objective of restructuring and mobilising the economy, and by 1992 the government had started to restructure and liberalise the economy. The measures adopted in the context of that programme were identical to the standard features of IMF/WB strategies although the programme was self-induced and it was carried out without any foreign assistance. Those programmes have affected the health sector and the health policies in the Sudan.
During the last two decades Sudan's national health policies witnessed a considerable development. There have been commitments by the government to achieve health for all the population by the year 2000. It was committed to realising that goal through the implementation of the Primary Health Care Approach. In 1992 the government framed the Comprehensive National Strategy (CNS) for socio-economic affairs covering the period 1992-2002. Strategies were designed to secure good health services and ensure the well being of the whole population.
However, the implementation of the programme of the CNS has been constrained by many factors, namely; lack of financial resources, shortage of trained human resources for health, and administrative problems resulting from implementation of Federal government law which led to the establishment of 26 states, instead of 9. Many of the new states inherited poor infrastructure for services. So there is a need for establishing new systems of management, logistics, financing, etc.
As a result of adopting SAPs, government spending allocated for health sector has been significantly reduced, although prior to the implementation of SAPs, this sector was facing a lot of difficulties because of the deterioration in the economic conditions. These difficulties were reflected in insufficient resources allocated for the sector, inefficiency in the utilisation of the resources, unsatisfactory and unequal geographical distribution of health care facilities and personnel, deterioration in the work environment, and the continuous decline in manpower in this sector.
After the implementation of SAPs and the cutback in the government funds for the health sector, the situation started to become severe. The curative health resources witnessed a sharp decline. That deterioration was manifested in the continuous decline in the curative health personnel. The number of general physicians declined by 35% during the period 1990/93, that of medical assistants by 10%, and that of nurses by 4% during the same period (Muneef, 1996). The serious decline in the number of professional personnel from the service was attributed basically to the deterioration in the living conditions of health workers who were suffering a continuous fall in their real income. The tendency of deterioration was also manifested in the lack of necessary expansion in the number of health care units and facilities needed to meet the increasing demand for health services by the growing population, and even the decline in the number of primary health care units which witnessed an average annual rate of decline of 4.2% during the period 1990/93 (Muneef, 1996).
On the other hand, the government started to change the existing method of funding through the public budget by introducing a system of cost-sharing whereby users are charged for the services. Although it was claimed that the imposition of user charges was to improve the quality of the services provided, it was primarily to offset the decline in the government's budget allocation to the health services and to ensure the sustainability of providing health services through channels other than the government budget. Despite the different titles under which that policy was implemented, its common feature is that the consumer must pay when seeking medical treatment in public health institutions. It is worth mentioning in this respect that no exemptions in payment are made for the poor and the other vulnerable groups, although some compensatory measures were implemented to help the poor who seek treatment in public health care units through provision of "Takaful" and "Zakat" funds support. But the fund was inadequate to meet the increasing demand for such subsidised services, as the number of applicants seeking support was growing as a result of the continuous increase in the cost of health services and the sharp decline in the real income of the people.
Furthermore, adoption of SAPs has led to a regressive effect on the standard of living of the population. According to Ali (1994), the number of poor families was 2.7 million in 1986. By 1994, that number was 3.4 million. Also it was revealed that the percentage of population below the poverty line was 77.8% and 91.41% in 1986 and 1994 respectively. Deterioration in real income, together with the imposition of charges and the cut-back in government spending on health services, added to the existing factors that negatively affected the accessibility of health services to the vulnerable groups and hence their health status.
This study tries to examine the impact of the macro economic reforms implemented in the context of SAPs, especially the most important part of the sectoral reforms relating to the imposition of user charges, on the health sector and on the health seeking behaviour of individuals in the Sudan.
The study aims at the following:
1- To examine the impact of SAPs on the health care physical facilities and personnel;
2- To evaluate the policy of imposing user charges, i.e., "economic treatment programme", and to show to what extent it has achieved its goals;
3- To identify people's health-seeking behaviour (utilisation of health services and other forms of care in case of illness), to examine the impact of the cost and quality on the demand for health services, and to assess whether any changes can be detected through time;
4- To examine the role and place of the compensatory measures initiated by the government to maintain the accessibility of health services for the vulnerable groups and the extent to which they have achieved their "desirable mitigating effect".
It is believed that changing the funding mechanisms of the health services (like general taxation, cost-sharing systems and insurance) would have serious implications for equity, utilisation, access, efficiency and quality in the health care system. Therefore, there is an urgent need to study the implications of these changes, which have been introduced in the health service system in the Sudan. Thus, the result of this study will be helpful to policy makers as well as to the general public.
The study hypothesises that:
1- The implementation of SAPs in the Sudan has significantly contributed to the deterioration of the health services provided by the public health institutions in terms of quantity and quality.
2- Access to health services has been negatively affected by the implementation of the SAPs.
3- The compensatory measures adopted to overcome the negative impacts of SAPs on the vulnerable groups in their demand for health services are not adequate to ensure their access to health services at the required standards.
The study was carried out in Greater Khartoum because of the concentration of health care facilities and personnel there. In this respect, Khartoum Teaching Hospital (KTH) and Omdurman Teaching Hospital (OTH) have been the major sources for our primary data since they represent two of the largest hospitals in the country. Another consideration is that their location in an urban area implies favourable working conditions in their service delivery. Hence, the results obtained from them would be very indicative of the degree and magnitude of the overall impact on urban and rural health institutions.
Both primary and secondary data are used in the study. Secondary-documented data has been collected from books, papers, reports and other official documents.
The secondary sources are expected to give statistical data on:
- The ratio of doctors and other assisting medical cadre to the total number of population;
- In-patient and out-patient attendance;
- Health services facilities including hospitals, beds, and health centres.
The study population consists of the following groups:
1) Patients, both in-patients and out-patients;
2) Health professions like doctors and nurses;
3) Administrative staff and other key informants.
1.7.4 Data Collection Techniques
Primary data has been obtained using a core questionnaire with patients.
The major items in the questionnaire are: -
- Social and economic background of the patient;
- Fee for service and exemption polices;
- Costs incurred in seeking treatment; subsidies received if any.
- Ability and willingness to pay for health services;
- Household coping strategies in case of major expense;
- The alternatives of the patient in seeking treatment
- Services needed and level of satisfaction.
Also interviews have been carried out with doctors, nurses, administrative staff and other key informants to investigate their experiences with service delivery and constraints to utilisation of services, and to determine strategies needed to deal with these issues. In addition, observations have also been utilised as a tool for investigating the situation in the health institutions.
The stratified simple random sample has been employed with patients taking into consideration the difference in economic and social conditions of the patients and the variations in the type of treatment sought in the hospital. The sample size is 145 patients, 61 of whom are out-patients while the remaining 84 are in-patients. Because it is difficult to find a specific frame for population size in the hospital as a result of fluctuations in the inflow and outflow of the patients, the questionnaire was filled by the patients in the two hospitals within fifteen days, selecting an average of 10 patients every day. As for the staff working in the hospitals (including nurses, general doctors, consultants, specialists, and senior managers), the selection has been done according to the number of years of work in the health sector since we had to carry out our investigation with those who have been working during the period before and after the implementation of SAPs.
In analysing the secondary data obtained on the impact of SAPs on the health sector, the study has adopted the "practical approach". This approach measures performance by comparing the results of the situation that prevailed in the health sector prior to the introduction of the policy measures with the results that have been obtained after introduction of the policy measures. This approach is known in the literature as "before and after approach", and it is the most widely used method of policy evaluation. We have taken the period from 1985-1989 as the "before" period and the period 1989-1995 as the "after" period. The period 1985-1995 was chosen because it had witnessed the bravest attempts at a full-fledged implementation of adjustment policies in the Sudan. However, because of unavailability of data sometimes which covers the last two years we had to be satisfied with the available data. Primary data obtained through the employment of the questionnaire was analysed using Statistical Package for Social Sciences (SPSS).
The report is divided into five chapters. Chapter One is an introductory one that offers the framework for the study. Chapter Two reviews the literature on structural adjustment programmes and health. The third chapter examines the impact of SAPs on the health care facilities and personnel in the Sudan. In Chapter Four we discuss the impact of SAPs on the access to health services. Chapter Five provides the summary and concluding remarks.
