Country profiles

Sudan

Overview

With an area of 2 506 000 km², Sudan is the largest country in Africa. The heart of the country, in terms of population, lies at the confluence of the Blue and White Niles. The complex of the "three towns," comprising the three largest cities, Khartoum, Khartoum North and Omdurman, is situated there and contains almost 20% of the population. The total population of Sudan was about 30 million in 1999. The urban population was estimated at 33%. About 2.2 million are still entirely nomadic. Sudan’s peoples are as diverse as its geography. There are about 19 major ethnic groups and a further 597 subgroups. The Sudanese age structure is very young, with 43.1% of the population below the age of 15 years (1994) and only 2.7% above the age of 65 years (1994). In 1996, the total adult literacy rate and the female adult literacy rate were estimated at 52.5% and 41.8%, respectively. The crude death rate was 11.5 per 1000 population in 1998. Also in 1998, the crude birth rate remained high, at 37.8 per 1000 population. The infant mortality rate was estimated at 108 per 1000 live births in 1996. Also in 1996, the under-5 mortality rate was calculated to be 157 per 1000 live births. Total life expectancy at birth was 54 years in 1995. Maternal mortality was estimated at 36.5 per 10 000 live births in 1993.

The main causes of hospital inpatient morbidity in the northern region were as follows: infectious and parasitic diseases (36.1%); diseases of the respiratory system (20.2%); complications of pregnancy, childbirth and puerperium (12.3%); symptoms, signs and ill-defined conditions (5.9%); and injury and poisoning (4.5%).

The per capita gross national product in 1988 was US$ 480.

Not only is the country politically committed to health for all by the year 2000, but health has also been declared the first national priority after security. The health policies give priority to communities lacking preventive and curative services. Priority is also being given to services for people with physical and mental disabilities.

The national health strategy lays special emphasis on:

• encouragement of national and foreign voluntary organizations to provide services through the existing health institutions under the direct supervision of the health authorities

• family health and reduction in morbidity and mortality rates among mothers and children, who represent 70% of the population

• encouragement of community involvement in the planning, implementation and supervision of the health services

• reinforcement of primary health care and the delivery of its integrated components through the area health system

• coordinated development of the different levels of the health system

• encouragement of scientific research into the more pressing health problems, including environmental pollution, endemic and epidemic diseases and malnutrition

• improvement of the managerial skills of personnel at all levels

• emphasis on coordination between health-related ministries and departments.

The design of the health care system in Sudan is based on primary health care and the "health era" concept, which is conceived as a decentralized health care system able to integrate, at district level, the existing vertical programmes, including preventive, curative and promotive activities, has been fully developed but not yet universally applied.

At village level, primary health care units represent the first level of contact between the community and the health services. Secondary health care is available in small towns through rural hospitals and urban health centres. Tertiary health care services comprise provincial, regional, university and specialist hospitals.

Over 50% of the communities in both urban and rural settings have leaders who are endorsed and supported by the government and who act as focal points for resolution of the various problems related to the management of programmes in their localities. Moreover, popular committees for health have been established at both village and national levels. These committees are involved in planning, execution, resource finding and allocation as well as supervision of health services in their localities. The committees are supported by national laws and regulations and are effective, powerful bodies.

Nongovernmental organizations play a recognized role in the delivery of health care. Recently, the Ministry of Health took concrete steps to regulate their work in such a way as to prevent duplication and provide integration and effective coordination with local health services. Nongovernmental organizations have been invited to participate in planning sessions and meeting at national and local levels.

The per capita Ministry of Health expenditure was US $3.1 in 1988-89. The Ministry of Health expenditure represented 0.5% of the country’s gross domestic product. Most multinational and international agencies work directly with individual health programmes within and outside the Ministry of Health, leading to vertical execution of the programmes.

In 1986, there were 2064 physicians, 219 dentists, 299 college-graduate nurses, 9651other nurses and 5580 midwives employed by the Ministry of Health. Half the physicians are located in the three largest cities. With respect to physical resources, in 1988, there were 2708 static primary health care centres and 503 mobile ones. Moreover, there were 16 general, 72 rural and 38 specialized hospitals. A national health research policy exists, formulated by the Health Research Sector Congress, chaired by the Minister of Health.

The health services suffer from acute shortages in trained personnel. There are no health human resources plans, and universities and other training institutions work in isolation from the Ministry of Health. Training and education are thus not directed toward meeting national needs.

MENTAL HEALTH

Prior to World War Two, there were hardly any organized psychiatric services for the care of mental patients.

Psychiatry in Sudan began in the 1950s under the guidance of the late Professor Tigani El Mahi, the father of African psychiatry. He pioneered, among other things, rural services and the open-door policy. His successor, Dr Taha A. Baasher, shouldered the responsibility and further extended the services to the periphery. He established the Mental Health Association of Sudan and the Sudanese Association of Psychiatrists. By 1950, the Clinic for Nervous Disorders, Khartoum North, was well established, and the Kober Institution was built to cater for 120 forensic psychiatric patients. This was followed by the establishment of four psychiatric units in provincial capitals, at Wad Medani, Port Sudan, El Obeid and Atbara. In 1964, a 30-bed psychiatric ward was built in Khartoum General Hospital. Finally, in 1971, plans were laid to start work on Omdurman Psychiatric Hospital, the first of its kind in the history of Sudan. The underlying policy was first to establish psychiatric units with close links with medical institutions and broad connections with community agencies. Other mental health developments include establishing a school for psychiatric medical assistants and organizing training courses for social workers and psychologists, for Sudan and other countries. Sudan played an important role in the WHO project "strategies for extending mental health into primary health care" (1975-81).

Within the framework of national health policy, the essential elements of the mental health programme focus on:

• development of a viable mental health system to be closely integrated with general health facilities and related social services

• provision of comprehensive mental health care and its promotion as an essential element of primary health services

• training in mental health of general health personnel and those working in related educationally and social institutions

• establishment of a national organizational body for systematic coordination of related activities and the promotion of mental health care, as seems appropriate.

Taking into consideration the national situation, the priority problems that had been identified, the perceived needs and the available resources, an attempt was made to assess what could be achieved, how it was to be achieved and by whom. Operationally, the planned programme included short-term and long-term targets with due emphasis on human resources development and extension of the mental health services to peripheral parts of the country.

The guiding principles were: close integration of essential mental health care with general health system to the primary health setting; development of training programmes for health personnel at all levels of the health service; development of an appropriate referral system with comprehensive recording of information; provision of essential drugs; and community involvement and close collaboration with other social sectors, agencies and organizations.

In 1990, a mental health unit/cell in the Ministry of Health was established. There is now a mental health board, supported by the Sudanese Psychiatric Association, which acts as an advisory body to the Minister of Health. Decentralization to district general hospitals occurred in the early sixties, and has now been implemented at the primary health care level. Training courses are available for undergraduates, psychiatric specialist trainees, medical officers, other health care staff and other caregivers, including a postgraduate course, for Sudanese and other doctors, leading to a diploma of psychological medicine. Forty-eight doctors who work at primary health care level have been trained in mental health for two weeks, and a one-week course was held for police and prison officers. The medical curriculum now incorporates community psychiatry at the University of Al Gezira. Four psychologists and four social workers underwent postgraduate training. Postgraduate training for doctors in psychiatry was started in Khartoum University in 1990, and 19 students were granted scholarships.

Intensive community involvement includes use of the mosque and input from religious healers as well as the Sudanese National Society for Mental Health and the Sudanese Institute of Traditional Medicine.

Narcotic drug dependence represents a serious problem in Khartoum. Measures to combat this are directed by the multidisciplinary Sudanese National Narcotic Control Board, with support from WHO.

There is extension to a general hospital and provision of more health personnel to clinics, mainly in the northern part of the country. Other units were updated. In existing mental health services, attention has been given to special groups such as migrants, vagrants, the elderly, refugees and the displaced, uncared-for children. School mental health has been introduced into the mental health programme. A list of essential drugs, which contains neuropsychiatric drugs at different levels, has been formulated.

In view of the fact that in the last two years, the number of states in the country has increased from 10 to 26, an essential priority in the plan of action is the establishment of mental health services in these new states. An important priority in this respect is the availability of the necessary logistics.

In the plan of action, training of human resources is the foremost priority. A four-year postgraduate course leading to an MD in psychological medicine was initiated in 1989. The first batch, 10 in number, qualified in 1994. The second batch, 12 in number, are under training. In view of the increasing needs, the postgraduate training programme has been considered among the current important priorities.

Though efforts have been made to evaluate the implementation of the proposed mental health programme, these must be more systematically planned and followed up.

Mental health research in Sudan has a long history, including collaboration with WHO and other bodies, in studies on schizophrenia and childhood problems and community studies, such as the Kalakla project. Mental health legislation forms a chapter of the Public Health Act of 1973. This was reviewed by the Sudanese Psychiatric Association in 1985.

The main constraints that face the development of the mental health progamme, can be summarized as follows: an increasing number of well qualified and experienced Sudanese psychiatrists and other mental health professionals have been leaving the country and this has created a serious problem for human resources; so far, there are no dedicated units for certain superspeciality areas, such as psychiatry of children; because of shortages of periodicals and good quality textbooks, students find difficulty in obtaining necessary mental health knowledge and relevant psychiatric references; shortage of essential psychotropic drugs is a serious constraint in the management of the mentally ill; and the lack of modern instruments (for example, modern electroconvulsive therapy machines, computer-tomography scanner) are among the serious constraints in the development of psychiatric care and the proper assessment and management of mentally ill persons.