Quantitative component
Socio-demographic profile of respondents
Among household respondents, there were 215 females (51%) and 203 males (49%). Approximately 68% of respondents were married and 26% were single in both the catchment areas of KTH and IBMH. For respondents who reported completing university studies or higher education, 39% were from the KTH catchment area while 48% were from the IBMH region, see Table 1. The mean income of study participants was 2245 Sudanese Pound (SDG). Low monthly income (based on minimum daily wages of Sudan) was reported by 4% of household heads within the KTH catchment compared to 5% in IBMH. Approximately 47% of households in KTH were composed of 5–10 members, while 55% of households in IBMH catchment area were of similar size. In both areas, the majority of household heads fell within an age range of 18–58 years.
Table 1
Sociodemographic profile of the head of households in catchment areas of KTH and me IBMH, Khartoum Locality Sudan, July – December 2015.
Characteristics
|
Household in KTH area1
N (%)
|
Household in IBMH area2
N (%)
|
Total
N (%)
|
Education
|
|
|
418
|
Illiterate
|
5(2%)
|
4(2%)
|
9(4%)
|
Non-formal
|
4(2%)
|
10(5%)
|
14(7%)
|
Primary
|
25(13%)
|
26(12%)
|
51(25%)
|
Intermediate
|
19(10%)
|
15(7%)
|
34(17%)
|
Secondary
|
69(34%)
|
58(26%)
|
127(60%)
|
University and above
|
77(39%)
|
106(48%)
|
183(87%)
|
Monthly income
|
|
|
418
|
High
|
123(62%)
|
141(65%)
|
264(64%)
|
Medium
|
68(34%)
|
64(30%)
|
132(32%)
|
Low
|
7(4%)
|
11(5%)
|
18(4%)
|
Age group (years)
|
|
|
418
|
18–38
|
87(44%)
|
105(48%)
|
192 (46%)
|
38–58
|
85(43%)
|
83(43%)
|
168(40%)
|
58–78
|
26(13%)
|
29(13%)
|
55(13%)
|
> 78
|
1(1%)
|
2(1%)
|
3(1%)
|
1 KTH = Khartoum Teaching Hospital catchment area; 2IBMH = Ibrahim Malik Teaching Hospital catchment area.
|
Availability, affordability, accessibility, and quality of health services
When measuring the perception of availability of health services across both catchment areas of KTH and IBMH, there were no significant changes before/after decentralization, Table 2. However, when comparing the change in perception of availability of health services before/after decentralization individually, both KTH (90% before vs 48% after, p < 0.0001) and IBMH (88% before vs 42% after, p < 0.0001) had significant decreases reported. Availability of health workers also decreased before/after decentralization comparing KTH (63% vs 48%, p = 0.002) and IBMH (60% vs 46%, p = 0.003) catchments. In addition, the perception of overall health service affordability decreased considerably for those in the KTH (53% vs 24%, p < 0.0001) and IBMH (55% vs 16%, p < 0.0001) areas. Despite a decrease in the availability and affordability of health services, availability of medications was reported before/after decentralization as increased in both KTH (31% vs 51%, p < 0.0001) and IBMH (31% vs 46%, p = 0.001) areas.
Approximately half of the study participants (n = 205) expressed their perception of change in affordability after decentralization implementation. 159 participants experienced the perception of worsening affordability of health services and their perception remained after decentralization. 33 participants perceived change in the affordability of health services from unaffordable to affordable after decentralization. 172 participants perceived change in the affordability of health services before/after decentralization to becoming unaffordable, while 52 perceived no change (p = 0.00).
Regarding accessibility to healthcare services, 168 participants reported a perception of change in accessibility to health services after decentralization (p = 0.00), Table 3. For 145 participants health services remained inaccessible before and after decentralization, while 41 participants perceived a change in the accessibility from inaccessible before decentralization to accessible after decentralization. 215 participants perceived the quality of health services had worsened following decentralization, while 25 participants perceived improvement in quality.
Table 2
Perceived effect of decentralization on availability and affordability by the head of households in catchment areas of Khartoum Teaching Hospital compared with Ibrahim Malik Hospital, Khartoum Locality Sudan, July to December 2015.
Elements
|
Response
|
Household in KTH area1
|
Household in IBMH area2
|
P value
|
Availability of health services
Before decentralization
After decentralization
|
Yes
|
179(90%)
|
192(88%)
|
0.28
|
No
|
20(10%)
|
27(12%)
|
Yes
|
95(48%)
|
91(42%)
|
0.12
|
No
|
104(52%)
|
128(58%)
|
Availability of health workers
Before decentralization
After decentralization
|
Yes
|
125(63%)
|
106 (48%)
|
0.002
|
No
|
74(37%)
|
113(51%)
|
Yes
|
119(60%)
|
100(46%)
|
0.003
|
No
|
80(40%)
|
119(54%)
|
Availability of medications
Before decentralization
After decentralization
|
Yes
|
61(31%)
|
67(31%)
|
0.54
|
No
|
138(69%)
|
152(69%)
|
Yes
|
101(51%)
|
101(46%)
|
0.24
|
No
|
98(49%)
|
118(54%)
|
Availability of health information
Before decentralization
After decentralization
|
Yes
|
71(36%)
|
70(32%)
|
0.2
|
No
|
128(64%)
|
149(68%)
|
Yes
|
85(43%)
|
73(33%)
|
0.03
|
No
|
114(47%)
|
146(67%)
|
Affordability of services
Before decentralization
After decentralization
|
Yes
|
105(53%)
|
121(55%)
|
0.34
|
No
|
94(47%)
|
98 (45%)
|
Yes
|
49(24%)
|
36(16%)
|
0.03
|
No
|
150(75%)
|
183(84%)
|
1KTH area = Khartoum Teaching Hospital catchment area; 2IBMH area = Ibrahim Malik Teaching Hospital catchment area. |
Consultation fees were reported as unaffordable after decentralization by 42% in the IBMH area compared to to 31.6% of households within the KTH catchment, (p = 0.001), The proportion of people in the IBMH area who perceived the cost of medications and lab investigations as affordable before/after decentralization was 7.4% and 11% respectively (p = 0.01), compared to 9.8% and 13.6% (p = 0.01) among respondents from KTH area, (Fig. 1). There was an association between perceived unaffordability after decentralization with consultations (p = 0.001), medications (p = 0.01) and laboratory investigations (p = 0.01), in both KTH an IBMH catchment area. Payment for healthcare services via health insurance support after decentralization was reported by 71% of respondents in IBMH and 58% in KTH catchment areas (p = 0.004).
Access to care was reported to be perceived as decreased after decentralization by both those in KTH and IBMH catchment areas, see Table 3. Within each catchment area individually, there was a greater reported decrease in access to health care before/after decentralization, KTH was 59% before vs 41% after (p < 0.001) and IBMH was 52% vs 30% (p < 0.001). Likewise, a decline in the quality of healthcare services after decentralization was reported by 62% of respondents in the KTH and 72% in the IBMH catchment areas (p = 0.02).
Table 3
Perceived effect of decentralization on the access and quality of services by head of households in catchment areas of Khartoum Teaching Hospital and Ibrahim Malik Hospitals, Khartoum Locality, July to December 2015.
Elements
|
Response
|
Household in KTH area1
|
Household in IBMH area2
|
P value
|
Access to care
Before decentralization
After decentralization
|
Yes
|
118(59%)
|
114(52%)
|
0.082
|
No
|
81(41%)
|
105(48%)
|
Yes
|
81(41%)
|
65(30%)
|
0.012
|
No
|
118 (59%)
|
154 (70%)
|
Quality of care
Before decentralization
After decentralization
|
Yes
|
94 (47%)
|
84 (38%)
|
0.041
|
No
|
105 (53%)
|
135 (62%)
|
Yes
|
75 (38%)
|
61 (28%)
|
0.021
|
No
|
124 (62%)
|
158 (72%)
|
1KTH = Khartoum Teaching Hospital catchment area. 2IBMH = Ibrahim Malik Teaching Hospital Catchment area. |
Determinant factors of affordability and availability
A univariate analysis revealed that payment for consultation, catchment area, access after decentralization, and type of payment were significant predictors of the perceived deterioration in affordability, see Table 4. The adjusted analysis model showed that individuals who paid > 100 Sudanese pounds (SDG) per facility visit and residing in the KTH area were 3.6 times more likely to report that affordability of a consultation had worsened. In comparison, those in IBMH area and who paid less than 100 SDG (OR 3.6, CI = 1.5-9.0, p = 0.005), were 5.9 times greater (OR 5.9, CI = 2.1–16.6, p = 0.001) to report worsening of affordability following decentralization. Individuals who did not have access to services in KTH were 4.5 times more likely (OR 4.5, CI = 2.1–9.8, p < 0.001) and in IBMH area, were 3.4 times likely (OR 3.4, CI = 1.8–6.4, p < 0.001) to state that affordability of consultation had declined after decentralization.
Table 4
Determinants of perceived affordability among households in catchment areas of Khartoum Teaching Hospital and Ibrahim Malik Hospitals, Khartoum Locality, Sudan, July to December 2015.
Determinants
|
OR (95% CI)
|
P value
|
OR (95% CI)
adjusted
|
P value
|
Gender (ref = male)
|
|
|
|
|
Female
|
0.90(0.55–1.48)
|
0.69
|
0.868(0.514–1.465)
|
0.595
|
Catchment area (ref = KTH)
|
|
|
|
|
IBMH
|
0.55(0.33–0.91)
|
0.019
|
0.63(0.30–1.30)
|
0.21
|
Access after decentralization (ref = no)
|
-
|
|
-
|
|
Yes
|
5.47(3.21–9.31)
|
0
|
4.54(2.12–9.76)
|
0
|
Payment for drug (ref < 20 SDG)
|
|
|
|
|
20–50 SDG
|
3.93(1.90–8.12)
|
0
|
|
|
50–100 SDG
|
1.23(0.54–2.82)
|
0.63
|
|
|
more than 100 SDG
|
7.57(3.04–18.84)
|
0
|
3.64(1.47–9.04)
|
0.005
|
Income group (ref = low)
|
|
|
|
|
Medium
|
0.68(0.07–6.63)
|
0.74
|
1.92(0.62–5.98)
|
0.26
|
High
|
0.50(0.03–7.54)
|
0.62
|
|
|
Annual cost (ref < 1000)
|
|
|
|
|
1000–4999
|
|
|
0.86(0.47–1.56)
|
0.61
|
5000–9999
|
|
|
|
|
10000–20000
|
|
|
|
|
> 20000
|
|
|
|
|
Type of payment (ref = health insurance)
|
|
|
|
|
User fee
|
1.97(1.19–3.25)
|
0.008
|
1.44(0.83–2.51)
|
0.2
|
IBMH Catchment area
|
Gender (ref = male)
|
|
|
|
|
Female
|
0.93(0.59–1.45)
|
0.75
|
1.14(0.61–2.12)
|
0.68
|
Catchment area (ref = IBMH)
|
|
|
|
|
KTH
|
0.57(0.36–0.91)
|
0.017
|
0.72(0.38–1.36)
|
0.31
|
Payment for investigation (ref < 20 SDG)
|
|
|
|
|
20–50 SDG
|
1.65(0.70–3.90)
|
0.26
|
2.15(0.75–6.18)
|
0.16
|
50–100 SDG
|
2.07(0.82–5.18)
|
0.12
|
2.12(0.72–6.23)
|
0.17
|
> 100 SDG
|
4.67(2.07–10.53)
|
0
|
5.91(2.10-16.58)
|
0.001
|
Monthly income (ref = low)
|
|
|
|
0.009
|
Medium
|
0.87(0.09–8.48)
|
0.91
|
0.37(0.03–4.72)
|
0.44
|
High
|
3.00(0.25–36.33)
|
0.39
|
2.92(0.18–46.88)
|
0.45
|
Access after decentralization (ref = no)
|
4.05(2.52–6.51)
|
0
|
3.37(1.79–6.36(
|
0
|
Annual cost (ref < 1000)
|
|
|
|
|
1000–4999 SDG
|
|
|
1.77 (1.00, 3.13)
|
0.05
|
5000–9999 SDG
|
0.79(0.08–7.80)
|
0.84
|
1.26(0.11–14.18)
|
0.85
|
10000–20000 SDG
|
1.00(0.10-10.54)
|
1
|
1.91(0.16–23.06)
|
0.61
|
> 20000 SDG
|
0.60(0.05–7.92)
|
0.7
|
1.13(0.08–16.8)
|
0.93
|
Type of payment (ref = health insurance)
|
|
|
|
|
User fee
|
1.95(1.23–3.09)
|
0.005
|
1.40(0.70–2.80)
|
0.34
|
Low income group KTH
|
Gender (ref = male)
|
|
|
|
|
Female
|
0.95(0.61–1.47)
|
0.81
|
0.98(0.54–1.77)
|
0.94
|
Catchment area (ref = KTH)
|
|
|
|
|
IBMH
|
0.47(0.30–0.73)
|
0.001
|
0.67(0.37–1.22)
|
0.19
|
Payment for consultation (ref < 20 SDG)
|
|
|
|
|
20–50 SDG
|
1.88(0.81–4.36)
|
0.14
|
2.56(0.86–7.57)
|
0.09
|
50–100 SDG
|
1.30(0.47–3.64)
|
0.62
|
2.14(0.64–7.15)
|
0.22
|
> 100 SDG
|
4.05(1.90–8.64)
|
0
|
4.54(1.62–12.77)
|
0.004
|
Income group (ref = low)
|
|
|
|
|
Medium
|
1.08(0.11–10.51)
|
0.95
|
0.25(0.02–3.17)
|
0.29
|
High
|
0.50(0.03–7.54)
|
0.62
|
0.20(0.008–5.05)
|
0.33
|
Access after decentralization ( ref = no)
|
|
|
|
|
Yes
|
4.39(2.77–6.97)
|
0
|
3.36(1.81–6.25)
|
0
|
Annual cost (ref < 1000)
|
|
|
|
|
1000–4999
|
|
0.999
|
|
0.999
|
5000–9999
|
|
0.999
|
|
0.999
|
10000–20000
|
|
0.999
|
|
0.999
|
> 20000
|
|
0.999
|
|
0.999
|
Type of payment (ref = health insurance)
|
|
|
|
|
User fee
|
2.44(1.56–3.82)
|
0
|
1.37 (0.80–2.35)
|
0.25
|
Qualitative component
A total of 40 healthcare workers (21 male and 19 female) participated in in-depth interviews. Approximately 82% were between 25–50 years old. An additional 20 community members (13 male and 7 female) were also recruited from the household survey. Socio-demographic profiles of participants were collected at the beginning of each interview following consent. Approximately half of the healthcare workers were employed for at least 10 years in the hospitals. Among community members interviewed, 14% were unemployed, 36% were housewives, 45% had income-generating work and 6% were retired.
Several themes emerged from the interviews. To protect participants’ anonymity, quotes presented in this section are labeled with participants’ information code only.
Fragmentation and unsatisfying quality of services after implementation of decentralization
There were similarities in responses regarding the transfer of services from KTH to IBMH being perceived as a cause of fragmentation of services in both facilities. After decentralization, some services were not yet fully implemented within IBMH, which affected availability. The respondents perceived decentralization implementation as a barrier to availability and obtaining quality of care in an affordable manner.
Some study participants - both community members and healthcare providers - related that there was no need for the transfer of services from central hospitals to district facilities. Instead, many respondents emphasized that the service should be improved in the peripheries by the establishment of fully equipped facilities, while KTH should be improved to continue as a tertiary hospital. Physical and geographical inaccessibility around catchment areas was also reported as a negative impact of decentralization. “Why should I have to go to Ibrahim Malik while the nearest facility to my home is Khartoum Hospital? Where can I be treated now? In my area, there is only a poorly equipped healthcare center and many private facilities” (Interview 22. 19/10/2015). As one healthcare provider stated: “Transference of service lacked staging and proper coordination, which led to the denial of life-saving services to patients who came to KTH”.
Community members and healthcare providers stated that before decentralization there were comprehensive services in KTH, where a cluster of services and specialties were located. Therefore, if the patient came for treatment in one of the specialty departments and was recommended for surgery, the department of surgery and surgical subspecialties were available within the facility. Some community members reported that the available staff at IBMH was junior, with poor qualifications, and that senior staff relocated to the private sector or outside the country. Additionally, there was no regular availability of specialists in the decentralized IBMH hospital. Moreover, stopping the assignment of the resident, non-specialist doctors, affected the quality of services because service delivery became dependent on trainee doctors (house officers and deputy specialists) as stated by both community members and health care providers. A health worker stated, “In my opinion, everyone who gets sick is better off going to Khartoum hospital where he/she can find comprehensive service. Now after decentralization, they have stopped Khartoum hospital, except for the surgery department which will be shut down in the coming days “. (Interview 4. 3/10/2015).
Unavailability of health services
Unavailability of health services was a central theme among study participants. They perceived that the decentralization process had decreased the availability of health services. Some mentioned that patients from the Khartoum state and other parts of Sudan lost the earlier well-established emergency services located at KTH, which were transferred to lower capacity and poorly equipped peripheral facilities. One healthcare worker reported: “There was a neonatology section which was also transferred and lost its position. It used to contain incubators and highly qualified nursing staff that was also shut down”. (Interview 43. 18/11/2015). Lack of preparation and lack of transfer of equipment during the process of decentralization were also mentioned by healthcare staff.
“The transference of service before the preparation of the peripheral facility led to inadequate services being delivered and unavailability of many types of healthcare services. In addition, due to inadequate investigation tools in the peripheral facilities, staff cannot deliver diagnostic services to patients and just do first aid and transfer patients to other facilities”. (Interview 43. 18/11/2015).
The transference of the medicine department from KTH to IBMH affected the delivery of trauma services, which are highly dependent upon consultative support and other medical departments as needed.
Unaffordability of health services
Participants considered costly and unavailable services, as a direct consequence of decentralization. User fee costs and the subsequent increase in consultation and medication charges were reported as significant barriers. These challenges were considered to be one of the primary barriers to affordability and consequently limiting equitable access to quality health services.
Participants specifically reported an increase in consultation service charges after decentralization from 17 SDG to 50 SDG, which some felt made services unaffordable in the district hospital despite being a public facility. There used to be a charitable collaborative treatment scheme to support vulnerable groups such as IDPs and those with low incomes. This, according to one community member had stopped after the implementation of decentralization (Interview 1. 2/10/2015).
Catastrophic cost was mentioned by community members as detrimental to seeking timely as well as good quality health care: “In this country, you may need to sell your house to cover hospitals’ bills” (Interview 21. 17/10/2015). “Even the basic needs of gauze and syringe aren't available and its us as citizens who buy them.” (Interview 8. 7/10/2015).
Access and the change in health seeking behaviors
Non-medical costs related to the physical inaccessibility of services such as transportation cost may affect health seeking behavior in the sense that one may choose to seek care in a closer private clinic. Some of the study participants in the Khartoum area pointed out that after decentralization; the healthcare services became more geographically inaccessible. The Khartoum hospital was easier to access due to its strategic location at the center of the capital and in an area of the junction of different transportation lines. As noted by a community member “This added additional transportation costs as peripheral facilities like IBMH, are located in the Southern area and have no direct transportation lines, especially for those coming from other states of nearest regions” (Interview 1. 2/10/2015). Another member expressed similar thoughts: “Hospitals services were transferred far from me and when considering transporting costs, I figured out that it’s better for me to seek care in private clinic. All this policy is generated in the favor of Al-Zaitona/a private hospital in the center of Khartoum Locality” (Interview 1. 2/10/2015).
Self-healthcare also emerged as a topic of concern community members and healthcare providers stated that there had been an increase in seeking treatment and consultation directly from pharmacies and/or laboratories, due to high cost of treatment at health facilities. “People now go directly to pharmacies instead of clinic and take drugs due to high cost of healthcare”. (Interview 19. 15/10/2015).
The correlated dearth of some services has contributed to increasing its cost, as a participant mentioned that ICU and newborn services are also unaffordable in the public facilities due to shortages and cost 1500–2000 SDG a day.
Community members and health providers argued that indirect implications of unaffordability of medicines are serious, as it might double the burden on individuals, causing long delays before treatment and sometimes several self-treatment attempts that may lead to negative health outcomes. As noted by a community member; “After seeing a doctor, drugs are very expensive, more than 30 SDG. So, it took me 4–5 days to get money”. (Interview 2. 2/10/2015).
“There is no free treatment at all, emergency drugs like ergometrine should be bought by the patient. Any patient buys his/her own medicine on his/her own money”. (Interview 59. 20/11/2015).