Health in Sudan

Sudan is still one of the largest countries in Africa even after the split of the Northern and Southern parts. It is one of the most densely populated countries in the region and is home to over 37.9[1] million people.

With this rise in population and bearing in mind the political issues that have plagued the country with war and hostility for the last 25 years, health care has become an afterthought and basically lost in the midst of what the government might believe to be more pressing matters. Sudan still has a long way to go to achieve its millennium developmental goals and to establish an adequate and efficient health care system that benefits every individual in the country.

Situation

History of health care in Sudan

History of the medical research and providing professional medical health care in Sudan could be traced back to 1903, when The Wellcome Research Laboratory was established in Khartoum as a part of the Gordon Memorial College.[2]

Recent health situation

Sudan, with an increasingly ageing population, faces a double burden of disease with rising rates of communicable and noncommunicable diseases.

  • The Sudan Household Survey 2010 showed that 26.8% of children aged 5 to 59 months had diarrhea, while 18.7% were sick due to suspected pneumonia in the two weeks before the survey was done.
  • Protein energy malnutrition and micronutrient deficiencies continue to be a major problem among children under 5, with 12.6% and 15.7% suffering from severe wasting and stunting, respectively. The most common micronutrient deficiencies are iodine, iron and vitamin A.
  • Concerning the MDGs, still 73 [range: 59–88] (Both sexes) out of every 1000 children born do not live to see their fifth birthday.[3] The Maternal mortality ratio per 100 000 live births estimated at 730 [380–1400] deaths per 100 000 live births in 2010.[3]
  • The MDG target for malaria has been achieved, although it remains to be a major health problem. In 2010, malaria led to the death of 23 persons in every 100 000 population; while in total over 1.6 million cases were reported.
  • The annual incidence of new TB cases for 2010 is 119 per 100 000, half of them smear-positive. TB case-detection rate of 35% is well below the target of 70%, but treatment success rate at 82% is close to the WHO target of 85%. With respect to HIV-AIDS, the epidemic is classified as low among the general population estimated prevalence rate of 0.24% with concentrated epidemic in two states.[1]

Water is a main cause to each of these.

Vital statistics

Period Live births per year Deaths per year Natural change per year CBR* CDR* NC* TFR* IMR*
1950–1955 452 000 233 000 219 000 46.5 24.0 22.5 6.65 160
1955–1960 510 000 251 000 259 000 46.7 23.0 23.8 6.65 154
1960–1965 572 000 268 000 304 000 46.6 21.8 24.7 6.60 147
1965–1970 647 000 281 000 365 000 46.5 20.3 26.3 6.60 137
1970–1975 737 000 298 000 438 000 46.2 18.7 27.5 6.60 126
1975–1980 839 000 317 000 522 000 45.1 17.1 28.1 6.52 116
1980–1985 950 000 339 000 611 000 43.6 15.5 28.0 6.34 106
1985–1990 1 043 000 361 000 682 000 41.7 14.4 27.3 6.08 99
1990–1995 1 137 000 374 000 763 000 40.1 13.2 26.9 5.81 91
1995–2000 1 242 000 387 000 855 000 38.6 12.0 26.6 5.51 81
2000–2005 1 324 000 373 000 951 000 36.5 10.3 26.2 5.14 70
2005–2010 1 385 000 384 000 1 001 000 33.8 9.4 24.4 4.60 64
* CBR = crude birth rate (per 1000); CDR = crude death rate (per 1000); NC = natural change (per 1000); IMR = infant mortality rate per 1000 births; TFR = total fertility rate (number of children per woman)

Life expectancy

Period Life expectancy in
Years		 Period Life expectancy in
Years
1950–1955 44.5 1985–1990 55.1
1955–1960 47.1 1990–1995 56.0
1960–1965 49.2 1995–2000 57.6
1965–1970 51.2 2000–2005 59.4
1970–1975 53.1 2005–2010 61.5
1975–1980 54.0 2010–2015 63.6
1980–1985 54.5

Source: UN World Population Prospects[5]

Health policies, systems and financing

The socioeconomics of Sudan were deteriorating after the separation of South Sudan, while there is still conflict in Darfur, South Kordofan and Blue Nile states. Sudan’s economy has suffered a great deal from this. Firstly from a fall in oil prices and more recently from the loss of revenue from South Sudan for oil transportation. In addition, there are continuing sanctions and a trade embargo. Due to these occurrences, funds for health have been cut, adding to the fragility of the health sector.[1] In the past, the health financing system in Sudan has undergone several changes, from a tax-based system in the late 1950s to the introduction of user fees along with social solidarity schemes such as the Takaful system.[6] The social health insurance scheme was implemeted in 1995, alongside which the private sector grew exponentially leading to increased out-of-pocket from households In 2006, free emergency care for the first 24 hours was announced free of charge, and the free finance policy for children under 5 and pregnant women was adopted in 2008. Sudan has also reviewed health system financing using the OASIS approach as a prelude to framing its national strategy for health financing. Also, the country has embarked on developing detailed roadmap for providing universal health coverage to its population.[1][6][7]

Communicable diseases

Malaria

Malaria is one of the most deadly and epidemic diseases that affects Sudan and the African region in general. This is mainly due to the high temperatures and inadequate infrastructure regarding drainage and sewer systems. Stangnant and still water that builds up and is not drained becomes a reservoir and breeding ground for mosquitoes. This leads to their large numbers in the affected area. Still, we have reason to believe that the effect and burden of Malaria is somewhat underestimated. In 2007 a study was conducted in Sudan which revealed underreporting of malaria episodes and deaths to the formal health system, with the consequent underestimation of the disease burden.[8]

Children less than five years of age had the highest mortality rate and DALYs, emphasizing the known effect of malaria on this population group. Females lost more DALYs than males in all age groups, which altered the picture displayed by the incidence rates alone. The epidemiological estimates and DALYs calculations in this study form a basis for comparing interventions that affect mortality and morbidity differently, by comparing the amount of burden averted by them. The DALYs would mark the position of malaria among the rest of the diseases, if compared to DALYs due to other diseases. Uncertainty around the estimates should be considered when using them for decision making and further work should quantify this uncertainty to facilitate utilisation of the results.[8] More epidemiological studies are required to fill in the gaps revealed in this study and to more accurately determine the effect and burden of the disease.

Yellow fever

The World Health Organization was notified by the Federal Ministry of Health of Sudan of an outbreak of yellow fever in 2012 which affected five states in Darfur.[9] The yellow fever outbreak resulted in 847 suspected cases including 171 deaths. To reduce the spread of yellow fever, The World Health Organization worked with The Federal Ministry of Health in Sudan on a vaccination campaign that halted the outbreak.[10]

Nodding disease

Nodding disease or nodding syndrome is a new, little-known disease which emerged in Sudan in the 1980s.[11] It is a fatal, mentally and physically disabling disease that only affects young children. It is currently restricted to a small region of southern Sudan.

HIV/AIDS

Sudan is bordered by seven countries in which HIV/AIDS is highly prevalent, therefore Sudan is susceptible to an increase in HIV/AIDS prevalence. In 1986, the first case of HIV and AIDS in Sudan was reported.[12] Sudan's HIV epidemiological situation is currently classified as a low epidemic, as of July 2011.[13]

Transmission

The main mode of transmission worldwide is through heterosexual contact, which is no different in Sudan.[12] However transmission varies in different countries, in the United States, as of 2009, men who had sex with men was the main mode of transmission, accounting for 64% of all new cases.[14] In Sudan however, heterosexual transmission accounted for 97% of HIV positive cases.

Statistics

As of January 5, 2011, the Adult(15-49) prevalence in Sudan was found to be 0.4%, an estimated 260,000 were living with HIV and there were 12,000 HIV related annual deaths.[15] A population based study was conducted in 2002 which estimated the sero-prevalence to be 1.6%. According to recent studies, the HIV and AIDS prevalence in Sudan among blood donors has increased from 0.15% in 1993 to 1.4% in 2000.[12] Sudan is considered to be a country with an intermediate HIV and AIDS prevalence[12] by the World Health Organization(WHO).[16]

Treatment, care and support

HIV/AIDS related-services have been introduced in all the states of Sudan. Free services have been provided across the country, which have significantly improved the life of people living with HIV.[13]

  • HIV/AIDS estimates as of 2014[17]
HIV prevalence53,000 [41,000 - 69,000]
Ages 15–49 prevalence rates0.2% [0.2% - 0.3%]
Ages 15 and above living with HIV49,000 [38,000 - 63,000]
Women aged 15 and above living with HIV23,000 [18,000 - 29,000]
Ages 0–14 living with HIV4,300 [3,600 - 5,200]
AIDS related deaths2,900 [2,200 - 4,200]

Polio

Sudan has been polio-free since 2009 but is vulnerable to transmission from refugees from high-risk countries. A polio vaccination campaign was launched in 2018, supported by the World Health Organization. 5 million doses have been provided.[18]

Non-communicable diseases

  • In Sudan, under-five mortality declined by 43 percent (on average, 1.5 percentage points per year) between 1965 and 2008 - from 157 to 89 deaths per 1000 live births. Improvements in under-five mortality during this period were driven primarily by reductions in child mortality (deaths among children aged 1–5). Progress in reducing infant mortality was slower by contrast – falling from 86 to 59 infant deaths per 1000 live births – at a rate of 0.7 percent per year.
  • Under-five mortality levels for Sudan are 30 percent lower than the average for Africa and 51 percent higher than the global average. Sudan’s under-five mortality rate is at the average for low-middle income countries
  • Mortality among children is heavily concentrated during their first year. An estimated 65 percent of deaths occurring before the age of five, happen during infancy (before children reach one year of age) and approximately 33 percent of deaths occurring before the age of five happen during the neonatal period (in the first 30 days after birth).[19]

Maternal health

  • Complications during pregnancy affect one three pregnant women and complications during labor or up to six weeks after delivery affect one in two pregnant women. Close to 50 percent of female deaths occurs during pregnancy, delivery or two months after delivery. In this high risk setting, access to a continuum of effective antenatal, intrapartum and post-partum care for pregnant women is critical.
  • In 2010, evidence-based maternal survival interventions (including professional antenatal and delivery care) covered 40 percent of women in need. (up from 35 percent in 2006).
  • Family planning and effective ante-natal care are among the maternal survival interventions with the lowest population coverage: In 2010, 11 percent of married or cohabiting women used some form of contraception. Unmet demand for contraception is particularly large among cohorts of women older than 30 years of age.
  • Between 2008 and 2010, while 73 percent of pregnant women reported attending at least one antenatal check-up, only 14 percent of pregnant women reported obtaining an effective package of antenatal services including four antenatal care visits, an assessment for blood pressure, urine screen for protein, a blood screen for anemia and two doses of tetanus toxoid vaccine.
  • Between 2008 and 2010, among women of reproductive age with a pregnancy, 73 percent of all births were delivered with the support of a skilled professional (births attended by a doctor, nurse midwife or village midwife) - up from 63 percent between 2004 and 2006. This increase in coverage was driven by an increase in the proportion of births delivered by auxiliary or village midwives. The gains in professional support during childbirth have benefitted women in rural and urban areas alike.
  • As 75 percent of women reside in rural areas and births primarily occur in the home (in 2010, 75 percent of births occurred in the home), a significant challenge in this setting is to ensure women have access to emergency obstetric care if needed. Emergency care requires the availability of unscheduled 24 hour services close to the home. In Sudan, only one in five women delivers in a facility. Expanding the availability [19]

Oral health in Sudan

Little data is found in literature about the oral health in Sudan before the 1960s. Studies conducted after that showed different results because they were carried out in different populations and clinical settings.

About 772 dentists are practicing in Sudan (2 dentists/ 100 000 ) in 2008.[20] Dental services are included in insurance schemes with the exception of dentures, orthodontic treatments and plastic surgery.[21]

Decay-missing-filled index

The decay-missing-filled index are indicators used to determine the status of dental caries. The table below is from a 1993 report reporting on such data.[20][22]

% Affected; dmf; 4-5 years old

Age

% affected

dmft

d

m

f

Year

4–5 years*

42

1.68

1.62

0.03

0.03

1990

* A total of 275 pre-school children in kindergartens from Khartoum were studied.

% Affected; DMFT; different age groups - Khartoum state,[20]

Age group

DMFT

D

M

F

Year

12 years (Khartoum State) [23]

0.5

0.4

0.03

0.03

2007-08

16–24 years[24]

4.2

2.9

1.2

0.1

2009–10

25–34 years

5.5

3.3

1.9

0.3

2009–10

35–44 years

8.7

4.1

4.2

0.3

2009–10

45–54 years

9.8

4.0

5.5

0.2

2009–10

55–64 years

12.2

3.9

8.0

0.3

2009–10

65–74 years

14.4

3.0

11.3

0.2

2009–10

75+ years

15.0

3.3

11.8

0.0

2009–10

Periodontal disease

% having highest score (CPI); Different Age groups

Age Group

Number of Dentate

0

1

2

3

4

Year

No Disease

Bleeding on probing

Calculus

Pd 4–5 mm

Pd 6+ mm

15 years [25]

160

45

23

33

0

0

1990

15–19 years

126

0

1

0

95

4

1991

35–44 years

101

0

0

3

71

26

1991

[26]

Cleft lip and palate

This malformation showed a prevalence of 0.9 per 1000 in Sudan. More girls are affected than boys, with a male:female ratio of 3:10. (44% cleft lip with cleft palate, 30% only cleft palate, and 16% cleft lip alone).[27]

References

  1. 1 2 3 4 WHO (2014). "Sudan: WHO statistical profile" (PDF). Retrieved September 6, 2015.
  2. ↑ Elsayed, Dya Edin Mohammed (July 2006). "National Framework for Ethics in Health Research Involving Human Subjects" (PDF). Sudanese Journal of Public Health. 1 (3).
  3. 1 2 WHO (May 2014). "Country Cooperation Strategy: Sudan" (PDF). Retrieved September 6, 2015.
  4. ↑ World Population Prospects: The 2010 Revision
  5. ↑ "World Population Prospects – Population Division – United Nations". Retrieved 2017-07-15.
  6. 1 2 Gaafar, Reem (June 2014). "Sudan Health System Financing review and recommendations" (PDF). The Evidence The Public Health Institute’s quarterly newsletter (10). Archived from the original (PDF) on February 3, 2016. Retrieved September 6, 2015.
  7. ↑ WHO (2015). "Health systems financing review: What is OASIS".
  8. 1 2 "The burden of malaria in Sudan: incidence, mortality and disability – adjusted life – years". 2007.
  9. ↑ "Yellow fever in Sudan - update" (Press release). The World Health Organization. 3 December 2013.
  10. ↑ "Yellow fever in Sudan". World Health Organization. Retrieved 28 June 2015.
  11. ↑ Lacey M (2003). "Nodding disease: mystery of southern Sudan". Lancet Neurology. 2 (12): 714. doi:10.1016/S1474-4422(03)00599-4. PMID 14649236.
  12. 1 2 3 4 UNAIDS, U., and WHO: assessment of the epidemiological situation. UNAIDS; 2004.
  13. 1 2 "HIV/AIDS prevention and control | Programmes | Sudan". WHO EMRO.
  14. ↑ Markowitz, edited by William N. Rom ; associate editor, Steven B. (2007). Environmental and occupational medicine (4th ed.). Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins. p. 745. ISBN 978-0-7817-6299-1.
  15. ↑ "Global Health Observatory Data Repository". Retrieved 14 January 2015.
  16. ↑ Summary Country Profile for HIV/AIDS (PDF), WHO, 2005, retrieved October 13, 2007
  17. ↑ "Sudan". UNAIDS. 2015.
  18. ↑ "Sudan launches anti-polio campaign to vaccinate 3 million children". African News. 17 July 2018. Retrieved 14 September 2018.
  19. 1 2 Maternal & Child Health in Sudan by Paul Gubbins & Damien de Walque
  20. 1 2 3 EMRO - MALMÖ UNIVERSITY. "Oral Health Database".
  21. ↑ WHO (2006). "Health Systems Profile- Sudan, Regional Health Systems Observatory- EMRO" (PDF).
  22. ↑ Raadal .., M (1993). "The prevalence of caries in groups of children aged 4-5 and 7-8 in Khartown, Sudan". Internat. J. Paed Dent. 3: 9–15.
  23. ↑ Nurelhuda NM, Trovik TA, Ali RW, Ahmed MF (2009). "Oral health status of 12-year-old school children in Khartoum state, the Sudan; a school-based survey". BMC Oral Health (9): 15. Retrieved September 7, 2015.
  24. ↑ Khalifa N, Allen PF, Abu-Bakr NH, Abdel-Rahman ME, Abdelghafar KO (2012). "A survey of oral health in a Sudanese population" (PDF). BMC Oral Health (12): 5.
  25. ↑ WHO Global Oral Databank - Niigata UNiversity. "Periodontal country Profiles".
  26. ↑ EMRO- MALMO UNIVERSITY. "Oral Health Database".
  27. ↑ Suleiman AM, Hamzah ST, Abusalab MA, Samaan KT (2005). "Prevalence of cleft lip and palate in a hospital-based population in the Sudan". Int J Paediatr Dent. 15: 185–189. doi:10.1111/j.1365-263x.2005.00626.x.
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