National Health Policy Role of NHIF in National

National Health Policy Role of NHIF in National health policy and implementation challenges February, 2018

Contents • Introduction • Policy components • Achievements • Challenges 2

Introduction • Health plays a key role in the national and international development framework. • The constitution states: “The State shall promote public health and guarantee equal access and free primary health care to all citizens”. • The Universal Health coverage(UHC) declaration 2017 also reaffirms that health is a human right, that the Government of Sudan is responsible to assure the health of its people • Equity in health is an expression of social justice. 3

Current situation of health financing • There is a significant increase in government health expenditure from 6% in 2012 to 9%. However, this is less than the Abuja target of 15%. • Public expenditure as a percentage of total health spending is 22%[6] • 54% of the population (21. 8 million) is covered by NHIF, most of which are poor people. • 74% of the poor are covered through subsidies from ZAKAT and the MOF. 4

Current situation of health financing • Health financing is inefficient due to presence of fragmented pools • Lack of split between purchaser and provider created inefficiency in management and compromised quality of services • Fee for service is the predominant payment mechanism used by NHIF which increase the cost of health services • Health financing is skewed towards hospitals (>80%) instead of primary care level 5

Key Policy transformational Shifts • From Health services and skill mix skewed towards curative TO comprehensive integrated and responsive health care based on PHC with a functional referral system • From out of pocket financed health care TO prepaid financed health system with protection of marginalized and vulnerable population. 6

Vision: To become the pioneers in insuring all the citizens and to guarantee provision of excellent medical services that lead to the social security. Mission: The National Health Insurance Fund is a consolidative Institution that offers excellent equitable and sustainable medical services that meet our clients delight. Objective : The National Health Insurance Fund is a consolidative Institution that offers excellent equitable and sustainable medical services that meet our clients delight. 7

Key objectives of health financing component Governance Collection Polling Purchasing Objectives Align implementation with Policy Sufficient and sustainable revenues Equitable management of revenues Effective utilization of revenues

Key objectives of health financing component Governance Collection Polling Purchasing Objectives En fo rci ng Align implementation with Policy he a fin lth f an ina cin l ri n. Sufficient and sustainable revenues sk g p pro oli tec cy w tio management Equitable of revenues n ill en su re Effective utilization of revenues

Key policy components (1) Governance • Exercise the role of NHCC as the main and supreme governing body • Develop technical committee to guide implementation of health financing policy among stakeholders • Split health service provision from purchasing and define roles and responsibilities among different partners • Establish national independent body for accreditation 0 f health facilities • Strengthen the health information system to respond to the needs of partners

Achievements Ø NHIF Act was approved earlier in 2016, and the General regulation issued in 2017 ØOne National board of directors with representatives from all States meeting quarterly Ø Characterized by centralized planning at H. Q and decentralized implementation at state level with unified structure and policies. ØThere is technical committee headed by H. E Undersecretary of health to execute the financing policy ØJoint plan with Mo. H developed and phased out until the end of 2020 guiding NHIF to be the health service purchaser

Challenges regarding governance • Activation of health coordination councils and technical committees at state level • Formulation and endorsement of joint plans at state level with the aim to achieve UHC • Develop an integrated health information system among partners • Strengthening monitoring and evaluation systems

Key policy components (2) Collection • Increase public finance for health • Improve public expenditure for NHIF at the state level through earmarking • Increase state contribution for health with the aim to achieve financial protection through NHIF • Adjust premiums according to actuarial studies and improve collection mechanisms

Achievements • Public spending for health increased from 6% in 2012 to 9% in 2017 • Increased government coverage of poor families from 750, 000 family in 2015 to 2. 9 million poor family in 2018 • State contribution to cover poor families: • Enrollment of (55, 000 family in Gadarif, 20, 000 family in Northen state and 12, 000 in River Nile state) • Earmark taxation for NHIF in west Darfur state (10, 000 family) • Issuance of decree in 10 states that link marginal enterprises with health insurance card acquisition

Achievements • Coverage of poor families by international organization: • Coverage of 15, 000 family by Islamic Aid organization • Coverage of 100, 000 orphan by Qatar Eid organization (the startup is by 17, 500 orphan) • Premiums increased for both informal and social security support sectors in 2017 • Partnership with UNHCR to cover 10, 000 refugees from Syria and Yemen

Challenges of collection • To continue government financing for health to attain UHC • Increase contribution of states to cover informal sector through earmarking policy introduction • Increase premiums to balance with costly health services and infliation

Key policy components (3) poolling • Overcome fragmentation in healthcare financing and guide shifting to pool different fragmented initiative into a single large pool • Improve pooling mechanisms within NHIF through central collection of premiums, and improve resource allocation to states • Align and direct international funds towards UHC and policy priorities

Achievements • Development of a plan to guide shifting of free care funds of under five to NHIF in 6 states • Partial shifting of resources from Zakat chamber to NHIF to cover 200, 000 new poor family reaching to 655, 000 poor family in total • Central pooling of NHIF premiums

Challenges of pooling • Integration with private fragmented initiatives into a single pool • Development of a system to efficiently allocate centrally pooled resources to states • Direction of international funds into the single pool to attain UHC

Key policy components (4) Health service purchasing • Define medical benefit package (Basic, Comprehensive) • Study cost of health services • Shift from input-based purchasing to strategic purchasing of health services and reform provider payment mechanisms • Assessment and accreditation of health facilities are prerequisites for contracting with NHIF

Achievements • Agreement on basic and comprehensive benefit package • Bulk purchasing of medicines and medical consumables from NMSF since 2012 • International technical assistance to support design and cost benefit package • First draft developed for strategic purchasing and payment mechanism to health service providers • Piloting capitation as alternative payment mechanism in north Kurdofan State

Challenges of health service purchasing • Ensure that the biggest share of resources is shifted towards PHC • Develop a unified fee schedule for medical services cross different states