Health financing in Sudan: key informant interviews in the wake of the 2023 conflict

BackgroundSudan is a large, landlocked, African country with a population of 46 million. It is considered a least developed country, and coverage of essential health services is low. In April 2023 fighting broke out between the Sudanese Armed Forces and the paramilitary Rapid Support Forces. The conflict quickly escalated and has claimed 9,000 lives so far, with hundreds of thousands of people internally displaced. It is unclear exactly how the war has impacted Sudans already fragile health financing system. MethodsWe conducted one-to-one semi-structured interviews with a purposive sample of experienced health financing policymakers and policy advisors working in- or with the Sudanese government. Five senior key informants were recruited using snowball sampling. Interview transcripts were analysed using thematic analysis, with reference to the WHO national health financing framework and Sparkes and colleagues political economy framework. FindingsConflict has undoubtedly undermined Sudans ability to mobilise, allocate, and distribute financial resources. However, the existing health infrastructure was already so weak, and state funds so meagre, that the challenges posed by fighting were overshadowed by themes around Sudans underlying structural issues: out of pocket payments account for over 70% of all health expenditure; the existing national insurance scheme only covers a minority of the population; and there is unclear delineation of responsibilities between purchasers and providers and between the federal and state ministries of health. Major themes emerged around governance, revenue raising, risk pooling, purchasing and service delivery, and external donor funding. ConclusionsInvestment in developing health financing capacity at the state level, implementation planning, blended financing for the national health insurance fund, donor coordination, and community mobilisation to agitate for greater risk pooling were identified as essential steps. Without robust mechanisms to pool risk and diversification of financing sources, it will not be possible to extend financial risk protection or basic health services to large sections of Sudans population.