International University of Africa

Faculty of Medicine and Health Sciences

African Medical Students Association

Health Problems in Africa: Is there any hope left?
10 11 January 2013 AD/ 28 -29 Safar 1434 AH Khartoum - Sudan

Major Health Problems in North Africa

Sudan

Prepared by:

Hana Khalifah, MBBS Level 5, Faculty of Medicine - IUA

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COUNTRY BACKGROUND
Sudan has just emerged from a protracted period of conflict that has brought disaster on its people, directly and indirectly. While some areas have witnessed war, others have suffered from the strain of hosting displaced populations, and yet others have been affected as a result of the diversion of resources meant for development. In addition, the country is prone to natural disasters, such as floods and droughts, and as a result of its geopolitical location, shares borders with nine other countries. It is also exposed to the outcomes of strife in neighboring countries Sudan is divided into seventeen states (wilayat, sing.wilayah). They are further divided into 133 districts; its located in eastern north Africa Boundaries: North: Egypt; East: Red sea; Eretria and Ethiopia; West: Libya, Chad and Central Africa; South: Southern Sudan Demographic data: Total area: 1,156,673 sq mi (1,861,484 sq km) Population (2011 est.; includes the population of South Sudan): 45,047,502.

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 Sudan has 597 tribes that speak over 400 different languages and dialects The people of Sudan have a long history extending from antiquity which is intertwined with the history of Egypt. Sudan suffered seventeen years of civil war during the First Sudanese Civil War (19551972) followed by ethnic, religious and economic conflicts between the Muslim Arabs of Northern Sudan and the mostly animist and Christian Nilotes of Southern Sudan Country health indicators Growth rate: 2.1%); birth rate: 33.2/1000 infant mortality rate: 78.1/1000; Maternal mortality ratio, 2008, Lifetime risk of maternal death: 1 in:32 life expectancy: 52.5;

THE NATIONAL HEALTH POLICY

The National Health Policy has been formulated within the context of a comprehensive peace agreement which puts an end to the many years of conflict that have disrupted the countrys social service institutions, including its health institutions and services. The policy also recognizes the opportunities created as a result of economic growth in the country. This policy is framed within the remits of the relevant provisions of the interim Constitution of Sudan, 2005, the Local Government Act, 2003, and the resolute state laws and decrees which have introduced and institutionalized decentralized federalism in the country. Furthermore, this policy draws from and builds on the 25-year health strategy and existing policies relating to reproductive health, child health, HIV/AIDS, the national drugs policy, the essential primary health care package and the 10-year human resources strategy. It also reiterates national and international commitments, such as the Alma-Ata Declaration and the Health-for-All Strategy, the Millennium Summit Declaration and other global strategies, such as Roll Back Malaria (RBM), Stop TB and the Global Strategy for the Prevention and Control of Sexually Transmitted Infections, including HIV/AIDS.

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The Policy Statements

In order to realize the vision and mission of the National Health Policy, guided by the principles as specified, policy statements are hereby set forth for the priority areas and are divided into the two subsets of structural issues and health care delivery issues. Each area will be subject to separate and extensive documentation and greater operational details in the form of 5-year strategic and 1-year operational plans. Furthermore, it is imperative that these areas are not emphasized or treated as vertical programs, but are developed in an integrated manner as part of the comprehensive system of health services in order to achieve the vision and mission of the National Health Policy.

Structural issues
Policy statements on structural issues will essentially require action at the systemic level but may also overlap with statements concerning issues related to health care delivery, and vice versa.

Governance and stakeholder involvement

The Government will endeavor to develop and strengthen a national health system within the framework of the interim Constitution, and for the assurance of good governance, the involvement of all stakeholders, and particularly communities, is an important parameter. All elements of the organization of the health system should act transparently and innovatively, ensuring adherence to values and ethics and promoting gender mainstreaming and teamwork in the discharge of their functions. For this purpose, at all levels of the health system, health councils with adequate representation of all partners will be constituted to oversee the development of health policies and strategies, essentially based on scientific evidence and critical analysis of situations, and will monitor their implementation. Federal level will be responsible for: the formulation of national policies, plans and strategies; national quality standards; health information and surveillance systems; mitigation of major or interstate disasters and epidemics; medicines policy and regulations; in addition to overall monitoring and evaluation, coordination, supervision, training and external relations. At federal level, the FMoH (federal ministry of health) will be the sole government body responsible forestablishing the National Health Policy in consultation with all related bodies.

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Public sector institutions involved in providing health care, including universities, military and police health services and the National Health Insurance Fund will comply with the provisions of the National Health Policy. States and regions will be responsible for the formulation of local policies, plans and strategies, according to federal guidelines. They are also responsible for the funding and implementation of plans. The locality or county is mainly concerned with the implementation of national/state policies and service delivery, based on the primary health care approach.

Organization and management of health system

The Government will continue to strengthen the devolved, decentralized health system, especially at local/district/municipal levels. At the heart of this policy statement is the assurance that everyone in need will have access to good quality health care. This objective will be achieved through the establishment and institutionalization of a sustainable local or district health system. The FMoH, for this purpose, will steer and lead the reform process and reorganize the existing health care delivery network based on: the priority of preventive care over curative care; a desire to serve underserved and conflict affected areas; consideration of the treatment of common childhood diseases and emergency obstetric/gynecological care; concern for remote and rural areas or urban areas; an emphasis on outpatient over inpatient services; and decentralization of health services with the aim of making the regional and Local health services self-sufficient and responsible for a given population.

Health care financing

Currently, only a small proportion of the Sudanese population is covered by health insurance schemes. The FMoH and the SMoH(State Ministry of Health ) will advocate for arevision of the current situation and will identify factors creating barriers toaccess and will evaluate the possibilities for the expansion of coverage. However, as in the foreseeable future, health financing will continue through public revenue, the Government will continue to fulfill its commitments made in 2006 at the Abuja Declaration, in Abuja Nigeria, Financing for Development: The Abuja Commitment to Action, to raise domestic public expenditure on the health sector to 15% of the total government expenditure. Furthermore, the FMoH will institutionalize national health accounts in order to document the flow of funds in the health

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sector. Also, the FMoH and the SMoH will take adequate measures to build the capacity of its staff in health economics and to improve the functions of health financing in the health system.

Health statistics and the information system

A typical well-functioning health information system ideally comprises of data on: disease surveillance; household surveys; registration of vital events; patient and service records; and programme-specific monitoring and evaluation. In Sudan, due to the absence of a robust health information system, surveys are only conducted periodically. These are often purpose specific and are rarely comprehensive. As statistics play an important role in measuring and monitoring the progress of a country on the road to development, including its achievement toward reaching the targets of the MDGs, the National Health Policy envisages designing and implementing a comprehensive health information system; revamping the existing disease surveillance system; conducting household surveys; performing registration of vital events; maintaining patient and service records; and conducting programme-specific monitoring and evaluation. Such a tool, which will also bring the private sector into the system, will promote evidence-based decision-making and enhance the capacity of managers to effectively analyze and utilize statistics. This policy requires government at all levels, as part of the health information system, to arrange the compilation and evaluation of data for publication at regular intervals, making such information useful not only for managers, planners and policy-makers, but also for researchers, academics, students and institutions. The training of relevant staff for capacity building in the monitoring and evaluation functions of all three levels of government will also be ensured.

MAJOR PUBLIC HEALTH ISSUES

As in many other developing countries, Sudan has not yet gone through the demographic and epidemiological transitions and its epidemiological profile is stilllargely dominated by communicable diseases, most of which are common diseases that can be prevented and/or treated at relatively low cost and using relatively simplestrategies. However, certain problems, in particular malnutrition

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and tropical diseases, are of a magnitude, often reaching crisis proportions, rarely seen in more stablesituations. Infectious childhood diseases (measles, diarrhea, acute respiratory infections (ARI), and vaccine-preventable diseases), along with malaria and often in combination with malnutrition cause a large burden of morbidity and mortality. For example, ARI and diarrhea account for respectively 24% and 14% of hospital admissions of under-5 children in northern Sudan, while in southern Sudan they are associated with respectively13% and 11% of all health facility visits. Malnutrition is at chronically high levels throughout Sudan, in both urban and rural areas, and is a major cause of death in humanitarian crisis situations. Chronic malnutrition among under-5 children in northern Sudan is estimated at 36%, while the prevalence of acute malnutrition in southern Sudan is as high as 15 to 20%. Maternal health is a significant concern in Sudan, as high fertility, female genital Mutilation (FGM), sexual violence, malaria, and poor coverage of skilled delivery care in many areas, increase the risks of maternal morbidity and mortality. The maternal mortality ratio in the 1980s in northern Sudan is estimated at 509 per 100,000 live births, and is undoubtedly higher in southern Sudan. Coverage of skilled delivery care in northern Sudan is 57% in northern Sudan, but only 6% in southern Sudan. Malaria is endemic to much of Sudan and epidemic in other areas, causing a major burden among both adults and children. Between 20 and 40% of outpatient consultations in both northern and southern Sudan are related to the disease. In northern Sudan, 16% of mortality in hospitals is attributed to malaria, with children under 3years at most risk. Maternal malaria is an important contributor to maternal mortality, perinatal mortality, and low birth weight. The estimated prevalence of HIV/AIDS in Sudan is 2.6%, indicating that the epidemic has become generalized in many parts of the country. The migration and social dislocation caused by conflict are obvious risk factors for further spread of the disease, and very high prevalence has been found among some higher risk groups. Sudan is also distinguished by its exposure to a host of other classic tropical diseases, many of which have largely been controlled in other countries. An example is visceral leishmaniasis (kala-azar), a disease spread by sandflies which is fatal if untreated, and which caused the deaths of tens of thousands in the Upper Nile region of southern Sudan in the

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1980s and 1990s. Others include guinea worm, schistosomiasis, onchocerciasis, meningococcal meningitis, and trachoma. Physical and psychological disabilities are prevalent, often resulting from the longer-term squeal of infectious diseases and maternal morbidity, as well as from the effectsof war and displacement. In northern Sudan, survey data indicates that 0.3% of children aged 5 to 17 have a physical disability, while 0.7% are reported to have mental disability. In southern Sudan, survey data shows high rates of reported disability among under-5s 9% with a physical disability and 1% with a mental disability likely related to the effects of war and famine. Chronic diseases of lifestyle and aging are starting to be faced by the urban elite. For example, arthritis and hypertension each account for 3% of reported morbidity in Khartoum State.

Health System Organization and Financing

In northern Sudan The Government health system in Sudan was challenged over the 1990s by a combination of decentralization of responsibilities and funding cuts. Under the federalsystem in place since the mid-1990s, responsibility for management and financing ofmost of the health system has been devolved to the States and localities. On the onehand, all but the best-off States and localities do not have sufficient financialresources, as well as managerial capacity, to fully take up their new responsibilities. On the other hand, government austerity measures have limited transfers of financialresources from the center to the States. These factors led to deterioration of the primary health care system, in particular in rural and peripheral areas. One estimate is that less than half of primary health care units are staffed with community health workers. Another result of these factors is significant regional disparities in health services, which follow the center-periphery pattern shown by the MDG indicators. Physicians are concentrated in Khartoum and the better-off north central States. In Khartoum, there are 35 physicians per 100,000 population, while in Darfur and most of Kordofan, there are 1 or 2. Such disparities in services are mirrored by weak planning and managerial capacities at the State and locality levels. Recently, increased government revenues (largely due to oil revenues) have allowed an increase in public expenditures on the

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health sector. Figure 4, shows that combined Federal and State spending on the government health system doubled between 1999 and 2002, and is budgeted to increase a further 70% in 2003. However, it is also shown that as a proportion of total government spending, public health expenditures have remained relatively constant at between 2 and 3%. Similarly, government spending on health has remained at less than 1% of GDP. Both in absolute and relative terms at perhaps US$4 per capita and under or around 1% of GDP government health spending in Sudan ranks among the lowest in the world.

Percentage Expenditure on Different Types of Services

However, total health expenditures seem to be considerably higher. Along with decentralization, reforms in the mid-1990s included a national health insurance scheme, institution of user fees at public facilities, and encouragement of private sector provision. Out-of-pocket payments for health services are therefore considerable, including significant expenditures by the well-off for care abroad. Although no data are available on household health spending, it is estimated that total out-of-pocket expenditures are large or larger than total government health spending (that is, 1% or more of GDP). In addition, the national health insurance scheme similarly spends around 1% of GDP, so that total health expenditures in northern Sudan are likely in the range of 4 or 5% of GDP, or US$15 to 20 per capita. This level would be consistent with the lower range of total spending in countries in Sub-Saharan Africa. Health spending in northern Sudan, however, seems to be highly skewed towards the better-off. Out-of-pocket payments, of course, benefit the better-off more than the poor, while the insurance system covers only 8% of the population, mostly government employees. At the same time, much government spending is focused on hospitals, which tend to be used less by the poor. Indeed, recent increases in government health spending seem to have been devoted to a considerable extent to the development of referral level facilities, leading to an unbalanced health system favoring hospitals and higher-level health cadres. While the total number of primary health care facilities decreased slightly from 6,413 in 1994 to6,184 in 2000, the number of general or rural hospitals increased from 162 to 200 and the number of tertiary-level hospitals increased from 78 to 109. Similarly, the number of medical schools has exploded in recent years, now totaling 24 public faculties and 5 private. This

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increase in the number of medical schools, which now produce approximately 1,400 physicians per year, came in response to markets for doctors in better-off urban areas of Sudan, but especially abroad, in particular the Gulf countries. Of 16,000 physicians registered in northern Sudan, only around 5,000 are working in the country. Both markets will soon be saturated. At the same time, doctors are reluctant to work in rural and peripheral areas, contributing to the regional disparities. Although the government has been working on its human resource challenges, in particular by elevating the status and responsibilities of nurses, considerable work remains in strategy development. For this, better understanding of market and individual incentives is essential. Development of the private sector in recent years, encouraged by the government, both supplied a market for (and is probably increasingly being driven by) the enormous production of doctors. Private health services, concentrated mainly in urban and better-off rural areas of northern Sudan, are perceived to be of better quality than government services, and tend to be accessed more by the better-off. In Khartoum, an increasing number of hospitals and clinics are run by the private sector, leaving lower-level primary care facilities to the public sector. NGOs are also playing an important role filling some of the gaps in coverage of the government system and serving populations which are not attractive markets for private providers, such as IDPs. In Khartoum, for example, the number of NGO health centers (114) is comparable to the number of government centers (118)

Health System Performance

Availability, Utilization, and Quality of Services Coverage of basic services in many areas is low, sometimes extremely low. As noted above, measles immunization coverage in 1999-2000 was 58% in northern Sudan and 34% in southern Sudan. Coverage of skilled delivery care is 57% in northern Sudan and 6% in southern Sudan. Overall averages mask large urban/rural and regional disparities in service availability and utilization. For example, a 2000 survey in northern Sudan found that 61% of under-5 children with reported fever in urban areas were treated with anti-malarial medication, compared to 42% in rural areas. Coverage of skilled delivery care in the Upper Nile region of southern Sudan is 0%,

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compared to 14% in the Equatorial region, 33% in Western Darfur State, and 70% in Al-Gazira State. There is also evidence that the poor have less access to services. In northern Sudan, households with higher economic status are more likely to obtain treatment with a private doctor or hospital, while poorer households are more likely to go to informal providers (traditional healers and drug sellers) or not seek treatment at all. The stark differences observed in southern Sudan are likely due to geographic access as much as to household economic status. The betteroff are more likely to seek treatment at a health facility, while the poorer are more likely to go to traditional healers or not seek treatment.

Key Public Health Programs

A number of key public health programs are important to health system performance. For the most part, key vertical programs in both northern and southern Sudan currently have limited coverage, awaiting Global Fund financing before scaling-up. Immunization: Coverage is low in many areas, in particular in southern Sudan, and is greatly dependent on externally-financed campaigns. Malaria control: Programs in northern Sudan have traditionally emphasized vector control and are now focusing resources on larger urban areas. Malaria programs in peripheral areas of northern Sudan and in southern Sudan are limited to sporadic preventive interventions, such as ITN distribution, as well as routine curative care at health facilities. Tuberculosis control: The national TB program in northern Sudan has had success in recent years in expanding coverage of DOTS, although only 40% of estimated cases are detected. In southern Sudan, tuberculosis programs are presently limited, covering perhaps 25% of the population. HIV/AIDS: The importance of HIV/AIDS has been recognized by the political leadership in both northern and southern Sudan. Programs, however, are still in their planning and pilot stages. Maternal health: As noted previously, coverage of skilled delivery care in northern Sudan is relatively high, due to a long-standing emphasis on training village midwives, but extremely low in southern Sudan. The effectiveness of delivery care in preventing maternal mortality depends to a great extent on the availability of

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referral to emergency obstetric care. Little information is available on this in northern Sudan, although it is known that such services are in place in many areas. In southern Sudan, it is known that such referral is impossible in most cases.

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The Main Health Problems-Non-communicable Diseases (NCD)

The mortality estimates for Sudan have a high degree of uncertainty because they are not based on any national NCD mortality data. The estimates are based on a combination of country life tables, cause of death models, regional cause of death patterns, and WHO and UNAIDS (United Nations AIDS) program estimates for some major causes of death (not including NCDs). The 10 leading diseases treated in health units for children age (0-4 years) in 2010 1- Pneumonia 2- Malaria 3- Diarrhea& E.G 4- Diseases of respiratory system 5- Acute tonsillitis 6- Acute bronchitis 7- Disorders of eye 8- Amoebiasis 9- Injuries involving multiple body regions 10- Disorder of ear & mastoid

Leading causes of hospital admissions in 2010

NVDS (1) Pneum(2) 11.4% 11.3% OBS&GYN(5) asthma 4.2% 3.1% Malaria 10.1% DM (6) 2.2% D&GE (3) 6.4% abscess 1.9% C\S (4) 5.6% anemia 1.8%

1- Normal vaginal delivery 2- pneumonia 3- diarrhea and gastroenteritis 4- caesarian section 5- obstetrics and gynecology 6- diabetes mellitus

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Leading causes of hospital deaths in 2010 Disease Septicemia Pneumonia Other heart diseases Circulatory disorders Malaria HEART FAILURE Acute renal failure M. Neoplasms Malnutrition DM Total 10 deaths Other diseases Total deaths Deaths 1616 1277 1192 1163 1023 946 945 909 949 607 10527 12603 23130 % death 7 5.5 5.2 5 4.4 4.1 4.1 3.9 3.7 2.6 45.5 54.5 100

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Health Facilities: The primary Health Care Centers (PHC) in Sudan are 6177. State Northern R. Nile Red Sea Gadarief Kassala Khartoum Gazeria Sinnar W. Nile B. Nile North Kordofan South Kordofan North Darfour West Darfour South Darfour Sudan Number of hospitals 27 33 16 28 16 49 66 25 29 17 28 19 20 6 17 438

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HUMAN RESOURCES FOR HEALTH

The primary concern in terms of human resources for health is to match the needs of the countrys health system as it is being rehabilitated, reconstructed and reformed. The declaration of the Government to upgrade nursing and allied health personnel training to post-secondary diplomas and Masters Programmes will continue to be pursued by authorities at relevant levels to match these needs. Hous emen Ge ne ral Reg istr ar Spe ciali sts Den tists Phar maci st Tech nicia n Me dic al As sist ant 83 25 Nu rse

3653

41 63

179 4

211 2

718

1111

9482

205 66

Statistical indicators for specialized doctors per 100.000 populations in 2010

The ratio of specialized doctors is 6.5 per 100.000 of population, 0.8 more than 2009. More than 24 specialized doctors per 100000 population in Khartoum state; There is one state (S. Darfur) have less than one specialized doctor per 100.000 of population

The Statistical Indicators for Technicians per 100.000 population in 2010

The ratio of technician is 22.9 techniques per 100.000 populations, 5.1 more than the last year. The ratio of technician is 96.1 per 100.000 populations in Khartoum state, 21.3 more than the last year. There are five states have more than 20 statistician per 100.000 population

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Statistical indicators for mid wives per 100.000population 2010 The ratio of mid wife is 35 per 100.000 population 0.9 less than the last year ; The ratio of mid wife is 36 per 100.000 populations in Khartoum state 0.7 less than the last year. There is one state (S. Darfur) has less than 20 mid wife per 100.000 population. With increasing in N/W Darfur.

Medical and Health Sciences Schools

26- medicine 9 nursing 9 dentistry 10 pharmacy 17 Medical Laboratories 5- radiology 6-veterinary medicine 6- public health 3- physiotherapy 2- anesthesia 2- health psychology

Health Challenges:
1. The health system in Sudan faces many complcated challenges, ranging from the high burden of communicable and non communicable diseases to economic constraints, poverty and regional disparities. Climatic factors resulting in natural disasters,such as floods and drought, pose further challenges to the system 2. The control of communicable diseases represents a major challenge to those providing health care services in Sudan Still the health situation in Sudan facing a major obstacles as
geography and ecology

Poverty economic disparities between urban and rural areas

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basic infrastructure and services food security Chronic conflict 7 rural-urban migration

Recommendations
i. ii. iii. Encouragement of health programs that enhance the improvement of health care awareness and delivery; Post graduate programs and researches should be supported; We should know and feel the health problems that are facing all African people which mainly are related to poverty and manpower; Possibilities for public/private partnerships should be explored associated with studies on the nature and quality of service effectively provided in public and private facilities.

iv.

References:
1- Sudan federal ministry of health report of 2010 2- WHO Sudan health report

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