Policy - private health sector


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Policy - private health sector

  1. 1. 1Policy for private health sector Foreword Table of contents 1 Policy for private health sector 1 Foreword 1 Table of contents 1 1.1 Introduction 1 1.2 Private ‘for profit’ health sector 2 1.3 Policy for the private health sector 2 1.3.1 Values and principles 3 Quality in health care 3 Consumer satisfaction and patients’ rights 4 Services first 4 1.3.2 National and international commitments 4 1.3.3 Vision 5 1.3.4 Mission 5 1.3.5 Policy implementation and monitoring 5 Policy implementation 5 Monitoring and evaluation 5 1.3.6 Policy statements 6 Certificate of need programme 6 Governance and categorization of service level 6 Employment of health workforce 7 Health information 7 Incentive to the private sector for investing in health 7
  2. 2. Self employment of health professionals 8 Cost of health service 8 Patient referral 9 Contracting out health services 9 Medical waste 10 1.4 Acknowledgement 10 1.1Introduction In Sudan both public and private sector provide health care. The practitioners of both these sectors practice allopathic and or traditional medicine. The allopathic or scientific or modern health care includes the preventive, promotive, curative, and rehabilitative services. In the public sector, invariably these services are provided by the Ministries of Health, Armed Forces, Police, Railways, Insurance organizations, Ministry of Higher Education etc. The private sector, including ‘not for profit’ or Non Governmental Organizations (NGOs) and ‘for profit’ has expanded rapidly. The former is mainly concentrated in the South, Darfur, and the war affected areas of Red Sea, Blue Nile and South Kordofan states. The private ‘for profit’ sector health care constitute mostly the curative care, although some solo clinics also provide primary care, excluding preventive and promotive services. There is a code of conduct for ‘not for profit’ component, but there is no clear policy to regulate ‘for profit’ part of the private sector. Therefore, there are often concerns for the quality and the cost of services offered by the private health services at various levels. 1.2Private ‘for profit’ health sector The ‘for profit’ part of private sector in Sudan has flourished, inter-alia, consequent to the macroeconomic and sectoral reforms implemented during the 1990s. It is provided by the individuals through solo clinics and or institutions like hospitals, polyclinics, health centers, maternity and nursing homes, dental clinics and hospitals, diagnostic labs etc. But, the private sector is mostly concentrated in urban areas, especially in Khartoum and Gezira states. Out of about 172 private hospitals and medical centers, 119 are located in Khartoum state. In addition, Khartoum has 739 specialist clinics, 539 GP clinics, 288 dental clinics, 799 private laboratories, 30 x- ray units, and 17 physiotherapy clinics. There is limited and often in-accurate information about access and utilization of health services. But, a recent survey showed that out of all patients seeking health care, 22% consulted private sector. In terms of hospital admissions and surgical interventions, the share of private sector was 31% and 7% of respectively. The exit interview revealed that 57% patients who consulted private sector were males while 43% were females. 22% of patients were under cover of an insurance scheme, while 47% came to seek diagnostic services. The cost of admission (per day hotel charges) in a private hospital ranged
  3. 3. between SDG 150 to 200 (USD 70 to 95) compared to the public sector hospitals, where the cost is SDG 10 (USD 5) per day. 1.3Policy for the private health sector While drawing a policy and defining the roles and responsibilities of the state vis-à-vis the private health sector in the overall context of the health system, it is useful to do it in relation to its core elements: governance, organization, funding, and service delivery. The governance is about assuring the stewardship or oversight which is clearly the responsibility of the state. Likewise, state would determine how the health system is organized for different levels of care (specialized, tertiary, secondary, primary and community care) and geographical regions. But, the share of responsibility between the state and the private sector and the mechanisms for the discharge or implementation of other elements can however, vary and may take following forms: (i) public financing and delivery; (ii) public financing and private delivery; (iii) private financing and delivery. This policy focuses on the mechanism whereby the private sector financed as well as delivers health care. But, it also deals with issues surrounding the other alternate mechanisms, i.e. public financing and private sector delivery of health services. 1.3.1Values and principles This policy is framed, within the provisions of the National Health Policy, for allopathic health services financed and delivered by the private sector. Specifically, it shares the guiding principles and the values of the National Health Policy: (i) social determinants of health; (ii) gender mainstreaming and equal opportunities; (iii) partnership and collaboration for health; (iv) quality in health care and assuring the clinical governance; and (v) consumer satisfaction and assuring the patients’ rights. While the details provided for these values and principles in the National Health Policy applies also to this policy, the quality in health care and patients’ right are explained further to highlight their importance. Furthermore, in the private sector, being profit oriented, there is a tendency of refusal to treatment, sometime even in emergency in case the patient is not able to pay. But, this policy promotes the slogan ‘patient first’. in health care Quality in health care is one of the values on which hinges this policy. Therefore, while it was mentioned as part of the values, it is reiterated as a specific policy statement. In order to ensure good quality health care the FMoH, in collaboration with the SMoH, will develop national standards for all levels of care—primary, secondary and tertiary—and for specialized medical, surgical, paramedical, nursing care, etc. In addition, standard operating procedures, clinical practice guidelines and protocols, including for health management, will be developed and or adapted. The FMoH, in collaboration with the SMoH, will develop mechanisms, like the voluntary accreditation scheme to measure performance against pre-established standards, and will devise measures for selected indicators and scores to be assigned to a league table for the reference of health care providers.
  4. 4. satisfaction and patients’ rights The private health sector is not only to provide services ‘for profit’, but is also charged with the responsibility to protect the patients’ rights and assure satisfaction of the consumers of its services. This policy emphasizes on the FMoH to take a stewardship role and take measures, including developing of a Patients’ Bill of Rights to provide, inter-alia, information on people’s rights in relation to information disclosure; choice of providers and treatment plans; access to emergency services; participation in treatment decisions; respect and non-discrimination; confidentiality of health information; complaints and appeals. first Given that private health sector works for profit, often it refuses care to the patients who cannot pay or are unlikely to pay. This denial of services is particularly dangerous in cases where the patient is in critical condition and land up as an emergency. No welfare state can accept such an attitude from any health care provider. This policy emphasizes on the health care provider that they should calculate profit on the overall business and not for each individual case it deals with. In addition, it calls on the ministries of social affairs for establishing a safety net through, for example, zakat fund, to pay the poor and destitute who seek health services from private sector in emergencies. 1.3.2National and international commitments This policy reiterates the government’s resolve and commitments made nationally as well as internationally, such as the Alma-Ata Declaration and the Health-for-All Strategy, the Millennium Summit Declaration and other global strategies, such as the Roll Back Malaria (RBM), Stop TB and the Global Strategy for the Prevention and Control of Sexually Transmitted Infections, including HIV/AIDS. The World Trade Organization (WTO) has set up a regimen asking member states to open their public services including health to trade and foreign investment. Sudan is not yet a member of WTO, but in this regard Investment Encouragement Act, 1992 provides quite lucrative incentives. Given that such moves are likely to create inequalities in health as well as affect adversely the local capacities, this policy requires the Ministry of Health to work with authorities to safeguard country’s public health structure. 1.3.3Vision The policy for private (for profit) health sector appreciates the role of the private health sector as complementary to the public health sector and crucial for building a healthy nation, and achieving the Millennium Development Goals and the overall social and economic development of the country. 1.3.4Mission The mission of this policy for private health sector is expand the coverage, ensuring the provision of quality health care in Sudan at a competitive cost, emphasizing the ‘win-win’ situation between public and private sectors in the provision of these services.
  5. 5. The role of the state, as envisaged in the policy for private health sector, is limited to the regulation of health services provided by the private sector. The government will take necessary measure to encourage private sector to increasingly invest in the health sector. 1.3.5Policy implementation and monitoring implementation The FMoH will create mechanisms, such as establishing a private sector health coordination committee/council at national level to oversee the implementation of the policy, including conducting advocacy and harnessing the political commitment to ensure that the vision and mission of the Policy is translated into strategic and operational plans. This will involve, inter-alia, making available the resources commensurate to the stated targets and creating conditions conducive to achieving the vision and mission. and evaluation The objectives of this policy, enshrined as policy statements, will be systematically monitored. The FMoH will take measures, including the provision of adequate resources to institutionalize the monitoring of the achievements towards policy objectives. For this, the FMoH, with SMoH, will select appropriate indicators and will install appropriate mechanisms to measure and monitor the achievement of the objectives of the policy. A consolidated periodic health report for all levels of care, which outlines developments in public health, will be generated. The health policy unit in FMoH will be the focal point to coordinate the formulation, implementation, monitoring and evaluation, and reporting on the achievements of the policy. 1.3.6Policy statements The health services provided at the solo clinics and larger institutions include, inter-alia, reception, admission, diagnosis, treatment through invasive and non-invasive procedures, transfusion, referral, discharge and follow-up. In addition, these institutions generate health information, conduct research and contribute to developing health professionals. of need programme The government will set up a Certificate of Need (CON) Programme as a regulatory process. Under this programme, it will be incumbent upon the applicant (private sector investor) intending to establish a health care facility or to add or expand service(s) in the existing health facility, to obtain prior approval of the competent authority. The CON process is required to ensure that the services proposed by the health care providers are needed for quality patient care within a particular region or community. In this manner, unnecessary duplication of services will also be prevented. Also, in cases, where there is more than one applicant, selecting the best proposal from amongst the competing applicants would ensure better quality health service.
  6. 6. and categorization of service level Whereas in the private health sector the market forces guide and determine the level of service provided, it is imperative to set certain criteria and standards. Effective and efficient healthcare delivery is dependent on the availability of the right mix of healthcare technologies required for the delivery of specific health interventions. Integrated Health Technology Package (iHTP) is a tool devised by WHO to ensure that all resources needed for any particular medical intervention are available in an adequate mix that is specific and particular to the local needs and conditions. The FMOH shall establish a system using the iHTP for assessing the efficiency and effectiveness of health services provided through a comprehensive technology GAPS analysis as a means to regulate the health services provision. of health workforce Health workforce constitutes the backbone of any health service, be it in the public or private sector. For the purpose of this policy, different categories of health workforce include: (i) health professionals, like doctors and nurses; (ii) associate professionals, like medical assistants and technicians; (iii) health management professions, like hospital/ health managers and accountants; (iv) associate management professions, like administrative staff; and (v) support staff, like clerks and drivers (WHO, 2006). The health facilities in the private sector shall have the required number of qualified health workforce according to the norm and standards set for the type and level of health facility. The private sector can employ public sector health workforce, provided that the latter works with the former in their off hours and that by taking this job in the private sector, their public sector assignment is not affected in terms of the quality and quantity. information The health information is vital for monitoring the health status and also managing the health services. This includes health statistics to derive information about health status, health care, provision and use of services and their health impact. Currently, only few health facilities in private sector link their statistics with the public sector. As a result, it is not possible to construct the status of the health of the population and the services offered either at the state or national level. This policy emphasizes the importance of the health information and linking the private sector health facilities with public sector health information system. For this purpose, the private health sector will be responsible for reporting on an agreed set of indicators according to the defined format and parameters. It will be required initially to submit the data on deaths, births and disease in terms of patients seeking ambulatory or inpatient care. Later, however more sensitive and sophisticated indicators will be added. to the private sector for investing in health The government adopted Investment Encouragement Act, 1992 to provide environment that is conducive for investment. Under this law, a range of incentives in terms of the concessions, facilities
  7. 7. and guarantees are provided to the foreign private investors. As a result, the country’s GDP has grown steadily over the past years. The government shall extend incentives to the private domestic as well as the foreign investment in health sector, particularly in the tertiary and secondary care, health professional training and the acquisition of new technologies. But, the privatization and deregulation increasingly contributes to inequity in health care provision. In order to address such issues, this policy emphasizes that the Ministries of Health both at the Federal and State level should devise incentive regimen, essentially complementary and not inconsistent with the provisions of Investment Encouragement Act, 1992 to attract investors in the less developed states and localities. y offered should be inversely proportional to the development index calculated at state/province level. employment of health professionals The medical schools in the public as well as private sector are producing doctors and other health professionals. But since the job opportunities are few, many of the young graduates don’t find jobs. As a result, there is “brain drain”, referred lately as the “gulf Tsunami” in reference to the open and unrestrained chance and access for the Sudanese consultants to work in the GCC countries, especially in Saudi Arabia. In order to curb this situation and to keep the Sudanese health workforce in Sudan, the government shall institute measures to enhance better job opportunities. A national body, like ‘Sudan Health Foundation’ will be established to organize and manage a trust fund to advance ‘interest free loans’ and other assistance, technical as well as administrative, to the different categories of health workforce needed for setting up health services. of health service The health services are offered at exponential cost in the private sector; and there is currently no check or regulation governing the tariffs. On top of that, the policy of privatization and deregulation has further increased the cost of health services. This situation, in addition to limiting the access of many to the health services, leads to many households facing catastrophe, pushing them to the poverty. Also the public sector health services, which are relatively cheaper, get overwhelmed, thus compromising their quality. This policy requires the government to set up a system for checking the cost of health care. This is important given the imperfect conditions in the health services market. The Ministries of Health will provide health services through public sector health facilities at a lower cost. However, since public sector is often considered inefficient and its services are deemed generally as poor quality, government shall undertake alternate measures. Therefore, a standing committee with representation of the government, private health sector, health workforce unions, patient associations, health insurance etc will be set up in the Federal Ministry of Health with the responsibility of determining tariff for different types/categories of health services by the private sector in different states.
  8. 8. referral Referral of patients from one level of care to the other and between private and public sector is essential for providing comprehensive health services to the population. There is currently an ad hoc system, whereby the patients are referred informally and on voluntary basis. This often results in unintended complications and deaths. This policy therefore emphasizes on the government to set up a mechanism for the public sector to accept patients from private sector and vice versa for services, including for diagnostic, transfusion, invasive and non-invasive procedures, and intensive care. Also, mechanism will be set up for the referral of patients from private to private provider. out health services The contracting out is a mechanism of combining the public sector financing with private sector delivering the services. The private sector may be asked, at the expense of the public sector, to provide services like laundry and central sterilization room, kitchen and catering, gardening and cleansing, etc. But contracts may also be made with private providers to organize and manage health services using public sector infrastructure. The contracting out arrangement is a sort of public-private-partnership. This policy intends to support this intervention. The government will develop a detailed mechanism for instituting arrangements to contract out support services and a defined health services package. This will include contracting process and contract management, including the monitoring and evaluation of services being provided. waste The generation of waste from healthcare, including from the treatment, diagnosis, or immunization, health-related research centers, and medical laboratories has rapidly increased over the past decade. The improper disposal of this waste poses a significant risk to human health and the environment. Some of the problems arising from the poor management of medical waste may include damage to humans by sharp instruments, diseases transmitted to the humans by infectious agents, and contamination of the environment by toxic and hazardous chemicals. Thus, the management of medical waste is a subject of major concern for any regulatory agency. Given the importance of the issue, this policy calls on the government to install mechanism for the safe disposal of medical waste, arising from the health services offered by the public or private health sector. Instead of traditional treatment method like incineration, which causes emission of toxic substances into the surrounding area and requires high operation and maintenance costs and the requirement of ash disposal, modern method of medical waste disposal be employed. Furthermore, this policy includes the safe disposal of the irreparable and condemned medical equipment in the remit of the medical waste. In this regard, the FMOH shall develop standards and guidelines, and set up systems for regular monitoring and checks. 1.4Acknowledgement Focal person: Dr. Salma M. M. Kanani In collaboration with respectful task force members
  9. 9. Dr. Mustafa Salih Mustafa, Assistant Undersecretary Policy and Planning Dr.Khalid Habbani, head of health economics and research department. Dr.Iman Abdlla Mustaf, Head Of Research Dept Dr. Elkhatim Elyas, Head Of Health Quality Assurance. Dr. Sara Hassan Mustafa, Head Of Health Planning. Dr. Ghaiath Hussien, Research Dept Dr. Ghaiath Hussien, Research Dept Dr. Ashraf Obeid, Private Sector-SGH 10