This was my first visit to NEF's (Near East Foundation) Dar Es Salaam Health Center since the opening last December of the new maternity room, a first too for women of this Khartoum settlement of people who have fled their country's violence. Now expectant mothers can come to the clinic, not only for pre-natal care, but also for the birth of their children. For the first time, they can expect clean and professional medical care, rather than having their children at home with the help of unlicensed traditional birth attendants.

And the news is good. Despite intense competition from midwives who have tradition and lower costs on their side, births at the new facility now average one per day...and continue to grow.

Also new to the Health Center is Dr. Khalid, a local resident of Dar Es Salaam, assigned by the Sudan Ministry of Health to provide care and oversee clinic services, including for the new maternity room. After more than two years of operations, local residents now know about services offered and trust those providing them and Dr. Khalid has his job cut out for him with ever increasing numbers of patients both for maternity care and general care.

"We need to meet this increased demand while pushing costs down, enabling us to offer better services for lower fees," he said, facing a difficult issue head on. "We have to think about the day this clinic will have to support itself from fees for service rather than NEF subsidies," he continued, adding, "In a community where incomes are as low as in Dar Es Salaam, this is extremely difficult and takes considerable care and planning."

BEST ALSO WORST

This is not easy in a clinic where doctors provide not only western style medical care, but also health education and outreach activities. Health educators and licensed midwives make regular visits to monitor health conditions and follow up on pregnant women and new arrivals. However necessary for mother-and-child, these are largely free services because few recipients can afford to pay. Further, at the clinic mothers and children are treated to a host of vital services not normally available and for which fees cannot be charged -- growth monitoring (baby weighing); health education and counseling; family planning, contraception, and nutritional supplements, among them.

Their costs have to be incorporated into other services or supplemented from philanthropic donors such as NEF and its supporters like the Packard Foundation and Population Council. United Nations agencies like UNICEF for children and UNFPA for population can be counted on for occasional, valuable, but not on-going, contributions. The Sudan Ministry of Health and Sudanese Red Crescent are willing to help, but their resources are limited.

One of the basic ways to promote financial self-sufficiency for health care is to link more cost effective urban centers where profits can be made on medical care; to clinics in poorer areas where fees are less and auxiliary services more important. In this way revenues can be moved within the health care system to support those most in need. Unfortunately, this is not now an option available to small independent clinics in areas like Dar Es Salaam where NEF works. NEF is cooperating with international and local nongovernmental organizations in the health field to explore alternative strategies of this type.

Also, finding staff willing to serve in isolated areas such as Dar Es Salaam is difficult. Much larger salaries and supplements are being paid for medical personnel in areas such as Darfur and for the southern and eastern states where relief and emergency assistance combined with emergency health care are on-going concerns. Under these conditions, Khartoum and its surroundings ironically are experiencing a shortage of qualified health care providers.

MORE COMPLEXITIES

Health care in Sudan has never been just about medical services. Perhaps you could say that about most of the world, but in places like Sudan the balance between medical and community services is even more precarious. All you have to do is look at the statistics on why people come to the clinic and the cyclical nature of the precipitating causes to understand the real culprit is how people are forced to live.

Malaria is endemic in the area and its incidence changes with the seasons. The rainy season brings an increase in stagnant water and the mosquitoes that breed there. We can talk prevention, but if people are uneducated and either do not understand or cannot afford the cost...we have achieved little. On the other hand increasing temperatures bring an increase in parasites. The conditions in which people live, the quality of water supplies, and the lack of proper sanitation facilities all lead to increasing illness. Babies and young children are particularly susceptible.

While proposed new linkages between water wells and a home-based distribution system will help, the water coming out of the tap is only as good as the water flowing into the system. New water systems and increased utilization bring another set of problems to which users have to adapt or face other perils.

To address these issues more effectively, the Health Center is engaged in discussions with the Sudan Red Crescent. They are in the process of retraining hundreds of thousands of their volunteers to expand their traditional role beyond first aid to more effectively address health and nutrition education, HIV/AIDS, birth spacing, water, and sanitation. NEF hopes to link with this program and bring volunteers to Dar Es Salaam, even train new volunteers in the area in a pilot program supporting health education and community health activities among residents.

YET MORE LINKAGES

For some time NEF has promoted cooperation between the Health Center and local schools; three of them receive our financial support and other assistance. Recently the clinic sponsored health education activities at the El Tagwa School for is 220 students and their parents. Plans are now being made for a series of annual health education activities for all area schools, based on an assessment of need and following an annual plan. These programs could be expanded to include community-sponsored campaigns and other community activities.

Currently the Dar Es Salaam Local Committee is surveying households to develop a statistical base for making health insurance available to local residents at a price of about $5 per month per family. Unfortunately the one-time cost of putting together the paperwork (birth certificates, etc.) required for registration can exceed $25 per person--expansive for poor people with large families. Fortunately the committee has arranged for the local Zakat (traditional Muslim charity) Fund to cover costs for many least able to pay.

Both school-based health education and the new health insurance will contribute substantially to making the clinic more self-sufficient. School-based activities will build relationships among the clinic staff, parents, and children. With health insurance, more residents will be able to take advantage of services the clinic provides. With health insurance, the clinic will subsidize fewer services and can concentrate on more basic health education and prevention.

Also the Health Center's Community Health Committee, composed of community leaders, has helped NEF establish and promote the center. This committee can in the future play an important role in improving overall health status.

Fatima Ahmed Haron, 25, is originally from Gadarif State in eastern Sudan, a high school graduate very interested in income generation. A member of the Dar Es Salaam Local Committee, she put it plainly: "We as a community need to increase our efforts to improve conditions in areas that cause sickness and disease as well as simply improving the quality of medical care and the cost we pay for it. NEF is our partner in this effort. Together we have an important job to do."

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