Written by Dr Zenira Elbasheer, ST4 Emergency Medicine, North West deanery
Edited by Anisa Jafar & Ahmed E O Ali
Since 15th April 2023, when intense fighting suddenly broke out in the capital Khartoum and later spread to other states, Sudan has become one of the most urgent healthcare emergencies. The country is facing the largest internal displacement crisis with 8.1 million people displaced, 6.3 million of these within Sudan itself.
Country healthcare context
Located in Northeast Africa, Sudan is the third largest country in the continent, with a population of approximately 47 million pre-war displacement. It has a relatively young population with 62% under the age of 24 and a median population age of 19.6 years.
Pre-war, there existed a great disparity in access to healthcare within Sudan. The capital, Khartoum benefits from the most hospitals and healthcare centres, both public and private. This is a significant reason for urban to rural migration as patients from other states travel to seek medical help in the capital. Khartoum is also where most of the country’s tertiary hospitals with specialised emergency units are located.
Fewer staffed hospitals are found in major cities in other states whilst rural areas will usually rely on smaller health centres, and in outlying provinces. In these places, standard health care, including emergency care, is usually absent.
Emergency care
Emergency Medicine (EM) is a relatively new specialty in Sudan. A residency program was established in 2011, and the first batch of fully certified local specialists graduated in 2016. Being so new and combined with the so-called ‘brain-drain’ there is a deficiency of trained EM doctors in the country. Most hospitals therefore lack 24-hour cover by a clinician trained in EM.
As per the Emergency Care System Assessment (ECSA) carried out by Sudan’s Federal Ministry of Health (FMoH) and World Health Organization (WHO) in 2018, up to half the population in central Khartoum had access to 24-hour facility-based emergency care with independent, non-rotating providers trained in emergency care. This dropped to around 25% in the periphery of Khartoum and then dropped further to almost 0% in rural areas. According to estimates by the Sudanese Emergency Physicians Association in 2018, this uneven distribution of capacity had led to attendances of 300,000 per year in some emergency units in the capital.
At that time, almost half of the country’s 101 Ambulances were under the Khartoum Ambulance Service. This was the only state with scene-to-facility transfer. Outside of Khartoum state, these ambulances were limited to inter-facility transfer only.
The ECSA was followed by a roadmap in July 2018, where action priorities were agreed and a timeline was developed. Between 2019 and 2023 the new Federal Lead Agency for Emergency Care and Ambulance Services, in collaboration with WHO, has reformed several emergency units, started the National Ambulance Project and disseminated the Basic Emergency Care (BEC) Course amongst other activities. Updates on progress can be found on the FMoH facebook page.
The impact of conflict: challenge and opportunity
Since April 2023, approximately 3.5million people have been displaced from Khartoum state. Within Khartoum, emergency health systems, which were already precarious have now become even more fragile. More than two thirds of hospitals in affected areas are completely out of service, with remaining health systems dangerously close to collapse. Shortages of medical staff and supplies, safe water and electricity are the biggest threats to these overcrowded structures even if patients can reach these limited services.
Whilst this has placed strain on limited health care service available to the other states, it has also presented some, perhaps unexpected, opportunities.
Displaced doctors, including senior specialists, who have relocated due to the war, have played role, under support of the Federal Ministry of Health (FMoH) in reviving and opening hospitals in the country’s other states. Some examples are the opening and expansion of emergency departments in Port Sudan and in police hospitals across the country where previously emergency care was limited or completely absent.
Concurrently following the launch of the National Ambulance Project, which is now in phase two, ambulances are now being provided to states outside of Khartoum. States such as Kassala are already benefiting from this move, alongside repair and repurposing of existing structures. External support from countries like Japan (including equipment, direct aid and training) and organisations like WHO delivering a Basic Ambulance Provider care course (in Port Sudan in December 2023), have contributed to ongoing expansion of pre-hospital emergency care.
Where next?
The ongoing devastation taking place within Sudan has been below the radar for much of the world. As desperate as this situation remains, some interventions have still managed to accelerate plans for a decentralised health service in the country, and in parallel this has expanded Sudan’s scope for of emergency services.
The Sudanese American Physician Association (SAPA), among other Sudanese medical diaspora organisations, have been involved in supporting the health system in Sudan both by renovating/ equipping facilities and training staff, as well as providing humanitarian relief. Other notable global organisations providing aid during this time include Médecins Sans Frontières (MSF) and the International Federation of Red Cross (IFRC) and Red Crescent Societies. SAPA is accepting donations to continue to support the country during this crisis.
Links/refs:
‘Assessment of the Sudan emergency care system and consensus-based action priorities’ ECSA 2018 report
Sudan Emergency Care Roadmap: WHO and FMOH meet to set priorities for strengthening the emergency care system in Sudan
Federal Ministry of Health: https://www.facebook.com/FMOH.SUDAN
WHO Sudan emergency: https://www.who.int/emergencies/situations/sudan-emergency
MSF Sudan: https://www.msf.org/sudan
SAPA: Sudanese American Physicians Association
SAMA activities in Sudan: Sudanese American Medical Association (sama-sd.org)
IFRC situation reports and timelines: https://www.ifrc.org/emergency/sudan-complex-emergency