Access to Health in Sudan

Mindful insights, including possible solutions and innovative ideas, are being offered here by a field engaged Sudanese General Medical Practitioner regarding the challenges and obstacles hindering an equitable access to health in Sudan

By Hanan Abdel Aziz Marhoum

General Medical Practitioner

Insights on Access to Health in Sudan

 

Being a General Medical Practitioner who worked for non-profit organizations from 2005 till 2017 in remote areas like Darfur Region, I do believe that I have compiled some insights and points of view regarding challenges and obstacles hindering access to health in Sudan. Though some of these insights might be very obvious and common knowledge to everyone whether inside or outside the medical field, yet I believe that we can still discuss it and give it a fresh look if we approach it from a different perspective.

Ultimately we can foresee and anticipate why and what factors are hindering our progress and innovation and hence hopefully we can alter and change and mould our innovative suggestions and solutions and be open to new ways of execution if we want to reach our goal which is provision of access to health to  ALL.

FACTORS AFFECTING ACCESS TO HEALTH IN SUDAN

Factors affecting access to health differ depending on whether the area targeted is rural or urban.

In Urban Areas main factors are:

  • Brain-Drain of medical staff: Many doctors and nurses migrate from the country just a few years following graduation leading to big human resource – HR gaps especially at the big hospitals and casualties which ultimately led to a decrease in the quality of care given to patients and in some incidents due to lack of qualified staff and/or experience resulting in professional medical mistakes and loss of lives.
  • Lack of motivation of staff: Due to the low salaries and incentives, staff can hardly afford their living let alone affording purchase of medical references or regular participation in advanced medical conferences/workshops/forums etc. as all these have to be done on the staff own expenses and desire without any financial support from the Ministry of Health except for post-graduates who are being given scholarships from the Ministry.
  • Lack of appropriate Infra-structure and appropriate medical staff: Most of the well-equipped and well-built hospitals in Khartoum are actually belonging to the private sector and very few are belonging to the Ministry of Health and this logically results in provision of quality care and services to the patients who can afford the high expenses and fees of the private sector hospitals, while those who cannot afford it will for sure head towards less equipped hospitals or health centers or even go to traditional healers and herbal medicines practitioners. Actually in the recent 10 years the herbal medicine practitioners evolved and flourished as more of the public approached them for treatment for various diseases including even cancer. They even requested from the government a legislation of their activities and even were on the verge of making their own pharmacies. They even had regular advertisements in the national media claiming they can treat all types of serious diseases and gained many believers among the general public!!
  • Inadequate allocated national budget: It is no secret that the budget allocated for health is about 1% of the national budget!!!!!! Of course Sudan being torn with conflicts and wars, the government allocated more funds to meet the needs and expenses of those conflicts. So what can the Ministry of Health do with such a small allocated budget? While affecting the National Strategic Planning for Health Services and Care, this also  affected the mapping and distribution of health services; and since adequate funds were not available, there was inadequacy and failure to execute those plans e.g. the return back of Malaria as a disease in Sudan, after it was almost completely eliminated following the withdrawal of Global Fund from financing malaria and TB programs.
  • The sanctions put by the USA on Sudan and its impact on the economic status of the country: It also led to a severe shortage in meeting the demands of pharmaceutical companies importing medical drugs as the Central Bank could not secure enough currency for them to be able to import adequate amounts of drugs. This resulted in a big crisis and shortage of life-saving drugs.
  • Alleviation of the financial support of medical drugs given by the Ministry of Health: this directly impacted the medicines related to chronic diseases such as renal failure, diabetes, and psychiatric diseases. Those who could not afford the purchase of their chronic regular medications had to stop taking them or to become irregular in taking those medications or to decrease their doses against and without medical advice or to seek alternative medicine drugs like honey, garlic etc.!!!!
  • Political Factors: The economic status and the continuous drop in the value of the Sudanese Pound against the US Dollar impacted negatively the public and, with the added shortage in life-saving drugs and the increased fees of medical care, people started to aggregate in protests against the previous regime. Finally they ended it in April 2019 and currently the new government is trying its best with the support of the International Community to recover and support improvements in all fields.

As for the Rural Areas I will not go into much details as they are very obvious and known: so poverty, lack of qualified Human Resources and medical centers, marginalization, centralization of medical care at Khartoum level only and the main cities, influence of traditional healers, lack of education and ignorance, lack of adequate and appropriate means of transportation, lack of electricity and other essential services etc.

CONCLUSION

If we look at all the above mentioned factors we find that they are all having a common denominator which is that they resulted from more than 30 years of being under Sanctions a country put on hold for that long and this impacted its economy, led to brain-drain and progressive continuous decline in all aspects of life not just Access to Health.

So how can we innovate?

Well first we should include everybody in the brain-storming and in the discussion, we as Sudanese we should focus on altering and shifting Sudan from being a poor country to a strong and better place.

Solutions and innovative ideas related to access to health in Sudan should be unique to us, adapted to our perspective and identity in order to be achievable and successful. It should include the reality of our ethnicity being both African and Arab, it should evolve knowing that Sudan with its different regions and states and many local languages resembles a continent with many different countries so what we can execute in one country might not be the ideal or suitable solution for the other country.

We should also include the opinions of the local staff and people and approach this issue from their perspective and adapt our innovative ideas accordingly especially as we still have some gender issues and Taboos as well as we still in some regions suffer from the harmful traditional practices.

Another aspect of access to health is the umbrella of the National Health Insurance which has under it all the employees but does not include those who have no jobs except some special categories. So, how can we include those deprived from it to ensure that access to health is for all?

Finally, Access to Health is a very broad topic and unique to each country in its execution and perspective as well as in approach. Innovative suggestions will be dependent on the local understanding and approach to the topic and without the participation of the local people nothing would be accomplished. Any innovation from abroad needs to be adapted to the local culture and has to include in it the political and economic as well as the understanding of the context for it to be realistic and acceptable by the targeted community.

 

The Oxford Statement and The MedsWeCanTrust Campaign

The path toward universal access to quality-assured medical products requires a multidisciplinary approach whereby pharmaceutical regulation is not seen (anymore) as a technical issue that is dealt with by technical experts in isolation, but rather as an important component of pharmaceutical systems, that is strictly interconnected to the other systems’ components; and that should benefit from collaboration with policy makers, health economists, social scientists, researchers etc.. 

In this regard, the recent publication, in the Lancet Global Health, of the Oxford Statement and call to action for global access to quality-assured medical products, is a welcome development

By Raffaella Ravinetto

Institute of Tropical Medicine

Antwerp, Belgium

The Oxford Statement and The MedsWeCanTrust Campaign

A Call for Equity in Global Health

 

Access to quality-assured medical products for all, is a fundamental prerequisite to achieve universal health coverage (UHC), but it is hampered by a variety of political, structural and financial problems. Among them, the high prevalence of substandard and falsified medical products, particularly in low- and middle-income countries (LMICs), represents a significant threat to individual and public health [1]. Health systems worldwide need to design and implement policies that ensure availability and affordability of quality-assured products.

Strengthening the capacity of National Medicines Regulatory Authorities (NMRAs) in LMICs is surely a key priority, given that to date less than 30% of the World Health Organization (WHO) Member States have a stringent NMRA, meaning a NMRA with the capacity to fully perform the functions required to ensure that medicines, vaccines and other health products, work and do not harm [2]. But problems faced by most LMICs are more complex and multifaced. In 2017, for instance, the Lancet Commission identified five areas that are crucial to essential medicines policies: assuring the quality and safety of medicines, but also paying for a basket of essential medicines; making essential medicines affordable; promoting quality use of medicines; and developing missing essential medicines [3].

This list of “priority policies” clearly shows that the path toward universal access to quality-assured medical products requires a multidisciplinary approach, including expertise in health systems, pharmaceutical regulation, quality assurance, intellectual property rights, health financing, social sciences etc. In this multidisciplinary approach, pharmaceutical regulation is not seen (anymore) as a technical issue that is dealt with by technical experts in isolation, but rather as an important component of pharmaceutical systems, that is strictly interconnected to the other systems’ components; and that should benefit from collaboration with policy makers, health economists, social scientists, researchers etc.

The recent publication, in the Lancet Global Health, of the Oxford Statement and call to action for global access to quality-assured medical products, is therefore a welcome development [4].  It comes as a follow up to the first-ever international Conference on Medicine Quality and Public Health (Oxford, United Kingdom, 2018). At that time, delegates had issued the short Oxford Statement, calling for investment, policy changes, and action to eliminate substandard and falsified medical products [5]. The newly-published Statement is significantly expanded with a Call to Action, in order to support some key-strategies of the WHO (i.e., the “Prevent, Detect and Respond” strategy; the Global Benchmarking Tool for NMRAs; and the WHO Prequalification team); to advocate for increased investments to build the capacity in regulation, manufacturing, supply chains and post-marketing surveillance; and to advocate for research on the impact of poor-quality medical products, and on the cost-effectiveness of interventions to eliminate them. The Call is accompanied by a detailed Research Agenda.

One decade ago -and perhaps, even more recently- the subject of poor-quality medicines was discussed by technical experts, and it was relatively neglected by other stakeholders in health systems and global health. Today, the Oxford Statement is supported by more than 150 signatories, issued from a variety of different professional backgrounds, skills and expertise, showing a growing  awareness of the importance of these “technical” aspects, for the performance of health systems and for the achievement of UHC.

As recognized by the signatories of the Statement, the Call to Action will be translated into concrete actions only if supported by multi-sector political commitment, and if accompanied by solid partnerships across key-stakeholders such as regulators; Ministries of Health, Finance, Trade, Research; manufacturers, distributors and purchasers of medicines; funding and implementation agencies; researchers; law enforcement agencies; and the civil society, including patients’ and grassroots organizations.  But it is already an excellent news that the initial call does not come from a group of “technicians”, but from a multidisciplinary group of committed individuals and organizations.

Those who wish to support this call, can join the #MedsWeCanTrust Campaign (https://medswecantrust.org/get-involved), a platform that raises awareness of the impact of poor-quality medicines, noting that this problem “cannot be confined to technical, isolated conversations”, since “they are a fundamental breach of patient trust with life-or-death consequences”. The Campaign strives to inspire collective action and unify a diverse and broad coalition of partners, for achieving the policy changes necessary to ensure that the medical products that reach people work. We hope that also PEAH’s readers will be inspired, and will contribute to spread the call.

 

References

[1] World Health Organization. WHO Global Surveillance and Monitoring System for substandard and falsified medical products. Geneva: World Health Organization, 2017. http://apps.who.int/medicinedocs/en/m/abstract/Js23373en/

[2]  https://www.afro.who.int/news/tanzania-first-african-country-reach-important-milestone-regulation-medicines

[3] https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)31599-9/fulltext

[4] Newton PN, Bond KC, on behalf of the Oxford Statement signatories. Global access to quality-assured medical products: the Oxford Statement and call to action. Lancet GH 2019; 7: e1609-11

[5] https://www.tropicalmedicine.ox.ac.uk/events/medicine-quality/mqph2018/oxford-statement

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Letter of support for AIFA (Italian Medicines Agency) Director General Dr Luca Li Bassi sent to Roberto Speranza, Italy's Minister of Health - 7 November 2019. The letter was signed by 21 organizations and 24 individuals

 Letter of support for AIFA Director General Dr Luca Li Bassi sent to Italy’s Minister of Health – 7 November 2019

   
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Financialization of Health and the Impact on Peoples’ Lives

Overexpansion of the finance industry remains one of the systemic drivers of rising inequalities, in the face of the international community’s engagement to reduce them through the 2030 Agenda. This article maintains that, while the right to health is constantly redesigned to play an ancillary role to financial markets, the global health community needs to raise its visual spectrum beyond diseases to better understand and address the speculative dynamics of finance advancing in the health sector, with little promise of sustainability. Actually, the financialization of global health is in the crosshairs at a time when complex questions arise around governance, democratic, cultural and market related relevant issues 

 By Nicoletta Dentico

Executive Director, Health Innovation in Practice (HIP), Geneva

Steering Committe Member, Geneva Global Health HUB

Financialization of Health and the Impact on Peoples’ Lives

 

We live in a globalized economic system that is bound to reproduce a vicious cycle of inequalities. Rising inequalities between the global North and the global South, the economically privileged and the marginalized, among different genders and minority identities, have been historically reproduced and structured across generations, so much so that these are today the defining feature of our time. It is an undeniable fact that global challenges such as climate change and environmental degradation affect us all as humans living on this planet. Yet, they do not affect us all equally. Indeed, the impact of global warming is mostly felt by those who have least contributed to it, by those who are most marginalized from public service delivery, most exposed to economic instability and environmental crises. Growing economic disparity and wealth concentration kindle political inequality in all parts of the world, by expanding the capacity of corporate and financial élites to influence policy-making at national and international level, and therefore protect their wealth and dominant positions, or outright privileges. There is indeed an urgent need for people’s movements to converge around a common agenda for taking back our economies, reclaiming public services and protect natural resources.

The efficient allocation of capital is one of the most valuable tasks in a global economy, and it is impressive to realize that while three decades ago the average holding period of a stock was four years, today it is only 22 seconds. This is to say that finance has a tremendous potential. But we can do much better. The 2008 global financial crisis is a stark reminder that laissez-faire did not work.  Financial markets left to themselves produced too-big-to-fail banks and did not trigger competition but rather oligopolies and vacancy of regulators. The prices of financial assets did not manage to signal the incoming crisis. The very high payments that come with profitable speculations which disrupt the economic system in countries and lead to collapse and misery for the million people affected – “financial weapons of mass distraction”, as investor Warren Buffet calls them – describe the route the world takes when “financial markets, financial institutions and financial élites gain greater influence over economic policy and economic outcomes”.  This is what the financialization of the economy is about. A process that ultimately threatens the very funding efforts needed to meet the Sustainable Development Goals (SDGs), and makes us all vulnerable to the frequent crisis cycles that the casino capitalism driven by digital high-frequency trading needs to survive.

Addressing this phenomenon is the focus of the report Spotlight on financial justice: Understanding global inequalities to overcome financial injustice, launched at  the end of September during the UN General Assembly in New York (http://citizensforfinancialjustice.org/resource/spotlight-on-financial-justice-understanding-global-inequalities-to-overcome-financial-injustice/).  Through five thematic areas – 1. food and land; 2. health; 3. women’s rights; 4. housing; 5. infrastructure –  the report illustrates how the overexpansion of the finance industry remains one of the systemic drivers of rising inequalities, in the face of the international community’s engagement to reduce them through the 2030 Agenda.

After the 2008 financial crisis started in the global North, the governance structures and the deregulation regimes that had got us there, especially the uncontrolled expansion of the financial sector over the real economy, finally raised enough red flags. Notwithstanding their direct responsibility in the global financial collapse, major  banks were bailed out by governments using taxpayers’ money. At the same time, those very governments were overruling their human rights obligations by resorting to austerity measures to balance the loss of public finance, thereby creating pervasive negative effects on peoples’ lives, and dignity, around the globe. Consequences included reducing communities’ access to natural resources, restrictions on housing and employment, a considerable decrease of access to basic public healthcare services.

Greek people know only too well what financialization of health means, through the harsh lessons of EU austerity cuts and loan agreements imposed by the trojka (the European Commission, the European Central Bank and the IMF) to the Greek government, without any consideration for their potential side effects. The Greek administration, as the report accounts, was forced to reduce investments and put severe strains on core social services, which severely undermined community resilience to the crisis. The national health budget suffered a contraction of 36% between 2009 and 2014, which resulted in the meltdown of the Greek public health system. Infant mortality rose by 50%, especially among infant younger than one year. Chronic disease increased by 24,2%, due to the collapse of the healthcare system and the absence of the needed medical treatments caused by lack of financial means.  Mental illness among the population soared from 3.3% in 2008 to 12.3% in 2013. Greece’s prescription for the shock to the healthcare system was state subsidized health insurance, but with the unemployment rate at 27%, many remained outside the eligible criteria. Cost sharing for healthcare increased remarkably even for those with insurance, while entitlement restrictions were introduced for childbirth and a range of other essential interventions.

The discourse on Universal Health Coverage (UHC) is today one of the driving institutional paths stimulating the penetration of private finance into the social arena of health, at country level. With different shapes, UHC is overall featured by concerted efforts to promote models of healthcare financing based on affordable user fees and voluntary health insurance schemes, alongside the expansion of privately owned healthcare infrastructures. In this way, loan based approaches like microfinance are opening up new opportunities for rent seeking from the poor. There has never been a more exciting time to be an investor in health, especially now that the combined burden of communicable and non communicable diseases is sharpening perceptions on the needs for health in lower income countries.

Beyond the health domain, the euphoria for financialization seems to have captured contemporary international development circles, primarily by means of multi-stakeholder partnerships. Escorting private finance into development is increasingly touted by alliances of multilateral institutions, national governments and owners of equity investment funds and private capital overall. The assumption is that multi-stakeholderism may be the solution to the current problems with the multilateral system[i], and that resorting to private money is the inevitable strategy if the world is to catch up for the estimated annual gap of US$ 2.5 trillion required to achieve the Sustainable Development Goals (SDGs) – a gap considered beyond the capability of public funding [ii].  The acceptance of an argument that makes poverty bankable finds in this context no institutional resistance. This is what drives new asset classes such as the impact bonds (like the Cameroon Cataract Performance Bond) or the catastrophe insurance schemes like the Ebola bonds, betting on international health outbreaks within the Pandemic Emergency Financial Facility.

The financialization of global health poses a range of complex questions:

  • a governance issue, due to the fragmentation produced in the health system and the hybridization of the role of health institutions at all levels;
  • a democratic issue, since financial markets are based on private agreements usually covered by a confidentiality clause. The use of public funding can be traced, at least in theory, while the same does not apply to private sector investments, which entails some negative externalities in terms of transparency and accountability;
  • a market related issue, to the extent that the provision of healthcare services may end up being exposed to the volatility of the financial casino;
  • a cultural issue, in the sense that health financialization may well influence consumerism, and people’s culture around the healthcare approach to be desired.

While the right to health is constantly redesigned to play an ancillary role to financial markets, the global health community needs to raise its visual spectrum beyond diseases to better understand and address the speculative dynamics of finance advancing in the health sector, with little promise of sustainability. This is urgent.

 

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[i]  Gleckman, H. (2019), “How the United Nations is quietly being turned into a public-private partnership: A new agreement with the World Economic Forum gives multinational corporations influence over matters of global governance”, OpenDemocracy, 2 July 2019, https://www.opendemocracy.net/en/oureconomy/how-united-nations-quietly-being-turned-public-private-partnership/.

[ii]  Hunter, B. and Murray, S.  (2019):  Deconstructing the Financialization of Healthcare, Development and Change 0(0): 1–25. DOI: 10.1111/dech.12517, p. 1