amsa-iua: conference proceedings_jan 2013-12. sudan

8/13/2019 AMSA-IUA: Conference Proceedings_Jan 2013-12. Sudan

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International University of Africa

Faculty of Medicine and Health Sciences

African Medical Students Association

Health Problems in Africa: Is there anyhope left?

10 11 January 2013 AD/ 28 -29 Safar 1434 AHKhartoum - Sudan

Major Health Problems in North Africa

Sudan

Prepared by:

Hana Khalifah, MBBS

Level 5, Faculty of Medicine - IUA


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COUNTRY BACKGROUNDSudan has just emerged from a protracted period of conflict

that has brought disaster on its people, directly and indirectly. Whilesome areas have witnessed war, others have suffered from the strain ofhosting displaced populations, and yet others have been affected as aresult 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 nineother countries. It is also exposed to the outcomes of strife inneighboring countries

Sudan is divided into seventeen states (wilayat, sing.wilayah). Theyare further divided into 133districts;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.
http://en.wikipedia.org/wiki/States_of_Sudanhttp://en.wikipedia.org/wiki/Wilayahttp://en.wikipedia.org/wiki/Grammatical_numberhttp://en.wikipedia.org/wiki/Districts_of_Sudanhttp://en.wikipedia.org/wiki/Districts_of_Sudanhttp://en.wikipedia.org/wiki/Grammatical_numberhttp://en.wikipedia.org/wiki/Grammatical_numberhttp://en.wikipedia.org/wiki/Wilayahttp://en.wikipedia.org/wiki/States_of_Sudan


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Sudan has 597 tribes that speak over 400 different languages anddialects

The people of Sudan have a long history extending fromantiquitywhich is intertwined with thehistory of Egypt.

Sudan suffered seventeen years of civil war during the FirstSudanese Civil War (19551972) followed by ethnic,religious andeconomic conflicts between the Muslim Arabs of Northern Sudanand the mostlyanimist andChristianNilotes 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 thecontext of a comprehensive peace agreement which puts an end to themany years of conflict that have disrupted the countrys social serviceinstitutions, including its health institutions and services. The policyalso 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 introducedand institutionalized decentralized federalism in the country.Furthermore, this policy draws from and builds on the 25-year healthstrategy and existing policies relating to reproductive health, childhealth, HIV/AIDS, the national drugs policy, the essential primaryhealth care package and the 10-year human resources strategy. Italso reiterates national and international commitments, such as theAlma-Ata Declaration and the Health-for-All Strategy, the Millennium

Summit Declaration and other global strategies, such as Roll BackMalaria (RBM), Stop TB and the Global Strategy for the Preventionand Control of Sexually Transmitted Infections, including HIV/AIDS.
http://en.wikipedia.org/wiki/Ancient_historyhttp://en.wikipedia.org/wiki/History_of_Egypthttp://en.wikipedia.org/wiki/Civil_warhttp://en.wikipedia.org/wiki/First_Sudanese_Civil_Warhttp://en.wikipedia.org/wiki/First_Sudanese_Civil_Warhttp://en.wikipedia.org/wiki/Ethnicityhttp://en.wikipedia.org/wiki/Animismhttp://en.wikipedia.org/wiki/Christianhttp://en.wikipedia.org/wiki/Niloteshttp://en.wikipedia.org/wiki/Niloteshttp://en.wikipedia.org/wiki/Niloteshttp://en.wikipedia.org/wiki/Christianhttp://en.wikipedia.org/wiki/Animismhttp://en.wikipedia.org/wiki/Ethnicityhttp://en.wikipedia.org/wiki/First_Sudanese_Civil_Warhttp://en.wikipedia.org/wiki/First_Sudanese_Civil_Warhttp://en.wikipedia.org/wiki/First_Sudanese_Civil_Warhttp://en.wikipedia.org/wiki/Civil_warhttp://en.wikipedia.org/wiki/History_of_Egypthttp://en.wikipedia.org/wiki/Ancient_history


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The Policy Statements

In order to realize the vision and mission of the National HealthPolicy, guided by the principles as specified, policy statements arehereby set forth for the priority areas and are divided into the twosubsets of structural issues and health care delivery issues. Each areawill be subject to separate and extensive documentation and greateroperational details in the form of 5-year strategic and 1-yearoperational plans. Furthermore, it is imperative that these areas are notemphasized or treated as vertical programs, but are developed in anintegrated manner as part of the comprehensive system of healthservices in order to achieve the vision and mission of the NationalHealth Policy.

Structural issuesPolicy statements on structural issues will essentially require

action at the systemic level but may also overlap with statementsconcerning issues related to health care delivery, and vice versa.

Governance and stakeholder involvementThe Government will endeavor to develop and strengthen a

national health system within the framework of the interimConstitution, and for the assurance of good governance, the

involvement of all stakeholders, and particularly communities, is animportant parameter. All elements of the organization of the healthsystem should act transparently and innovatively, ensuring adherenceto values and ethics and promoting gender mainstreaming andteamwork in the discharge of their functions.

For this purpose, at all levels of the health system, healthcouncils with adequate representation of all partners will be constitutedto oversee the development of health policies and strategies, essentially

based on scientific evidence and critical analysis of situations, and willmonitor their implementation. Federal level will be responsible for: theformulation of national policies, plans and strategies; national quality

standards; health information and surveillance systems; mitigation ofmajor or interstate disasters and epidemics; medicines policy andregulations; in addition to overall monitoring and evaluation,coordination, supervision, training and external relations.

At federal level, the FMoH (federal ministry of health) will bethe sole government body responsible forestablishing the NationalHealth 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 theNational Health Insurance Fund will comply with the provisions of theNational Health Policy. States and regions will be responsible for theformulation of local policies, plans and strategies, according to federalguidelines. They are also responsible for the funding andimplementation of plans. The locality or county is mainly concernedwith the implementation of national/state policies and service delivery,

based on the primary health care approach.

Organization and management of health systemThe Government will continue to strengthen the devolved,

decentralized health system, especially at local/district/municipallevels. At the heart of this policy statement is the assurance thateveryone in need will have access to good quality health care. Thisobjective will be achieved through the establishment andinstitutionalization of a sustainable local or district health system.

The FMoH, for this purpose, will steer and lead the reformprocess and reorganize the existing health care delivery network basedon: the priority of preventive care over curative care; a desire to serveunderserved and conflict affected areas; consideration of the treatmentof common childhood diseases and emergency obstetric/gynecological

care; concern for remote and rural areas or urban areas; an emphasis onoutpatient over inpatient services; and decentralization of healthservices with the aim of making the regional and Local health servicesself-sufficient and responsible for a given population.

Health care financingCurrently, only a small proportion of the Sudanese population is

covered by health insurance schemes. The FMoH and the SMoH(StateMinistry of Health ) will advocate for arevision of the current situationand 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 publicrevenue, the Government will continue to fulfill its commitments madein 2006 at the Abuja Declaration, in Abuja Nigeria, Financing forDevelopment: The Abuja Commitment to Action, to raise domestic

public expenditure on the health sector to 15% of the total governmentexpenditure. Furthermore, the FMoH will institutionalize nationalhealth 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 thefunctions of health financing in the health system.

Health statistics and the information systemA 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 theabsence of a robust health information system, surveys are onlyconducted periodically. These are often purpose specific and are rarelycomprehensive.

As statistics play an important role in measuring and monitoringthe progress of a country on the road to development, including itsachievement toward reaching the targets of the MDGs, the NationalHealth Policy envisages designing and implementing a comprehensivehealth information system; revamping the existing disease surveillancesystem; conducting household surveys; performing registration of vitalevents; maintaining patient and service records; and conducting

programme-specific monitoring and evaluation. Such a tool, whichwill also bring the private sector into the system, will promote

evidence-based decision-making and enhance the capacity of managersto 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 datafor publication at regular intervals, making such information useful notonly for managers, planners and policy-makers, but also forresearchers, academics, students and institutions. The training ofrelevant staff for capacity building in the monitoring and evaluationfunctions of all three levels of government will also be ensured.

MAJOR PUBLIC HEALTH ISSUESAs in many other developing countries, Sudan has not yet gone

through the demographic and epidemiological transitions and itsepidemiological profile is stilllargely dominated by communicablediseases, most of which are common diseases that can be preventedand/or treated at relatively low cost and using relativelysimplestrategies. 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 malariaand often in combination with malnutrition cause a large burden ofmorbidity and mortality. For example, ARI and diarrhea account forrespectively 24% and 14% of hospital admissions of under-5 children innorthern Sudan, while in southern Sudan they are associated withrespectively13% and 11% of all health facility visits.

Malnutrition is at chronically high levels throughout Sudan, inboth urban and rural areas, and is a major cause of death inhumanitarian crisis situations. Chronic malnutrition among under-5

children in northern Sudan is estimated at 36%, while the prevalenceof acute malnutrition in southern Sudan is as high as 15 to 20%.

Maternal health is a significant concern in Sudan, as highfertility, female genital Mutilation (FGM), sexual violence, malaria,and poor coverage of skilled delivery care in many areas, increase therisks of maternal morbidity and mortality. The maternal mortality ratioin the 1980s in northern Sudan is estimated at 509 per 100,000 live

births, and is undoubtedly higher in southern Sudan. Coverage ofskilled delivery care in northern Sudan is 57% in northern Sudan, butonly 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 and40% of outpatient consultations in both northern and southern Sudan arerelated to the disease. In northern Sudan, 16% of mortality in hospitals isattributed to malaria, with children under 3years at most risk.

Maternal malaria is an important contributor to maternalmortality, perinatal mortality, and low birth weight. The estimated

prevalence of HIV/AIDS in Sudan is 2.6%, indicating that the epidemichas become generalized in many parts of the country. The migration andsocial dislocation caused by conflict are obvious risk factors for furtherspread 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 otherclassic tropicaldiseases, many of which have largely been controlled inother countries. An example is visceral leishmaniasis (kala-azar), a diseasespread by sandflies which is fatal if untreated, and which caused the deathsof 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 andmaternal morbidity, as well as from the effectsof war anddisplacement. In northern Sudan, survey data indicates that 0.3% ofchildren aged 5 to 17 have a physical disability, while 0.7% arereported to have mental disability.

In southern Sudan, survey data shows high rates of reporteddisability among under-5s9% with a physical disability and 1% witha 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 for3% of reported morbidity in Khartoum State.

Health System Organization and FinancingIn northern Sudan

The Government health system in Sudan was challenged over the1990s by a combination of decentralization of responsibilities andfunding cuts. Under the federalsystem in place since the mid-1990s,responsibility for management and financing ofmost of the healthsystem has been devolved to the States and localities. On the onehand,

all but the best-off States and localities do not have sufficientfinancialresources, as well as managerial capacity, to fully take uptheir new responsibilities. On the other hand, government austeritymeasures have limited transfers of financialresources from the centerto the States. These factors led to deterioration of the primary healthcare system, in particular in rural and peripheral areas. One estimate isthat less than half of primary health care units are staffed withcommunity health workers.

Another result of these factors is significant regional disparitiesin health services, which follow the center-periphery pattern shown bythe 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. Suchdisparities in services are mirrored by weak planning and managerialcapacities at the State and locality levels.

Recently, increased government revenues (largely due to oilrevenues) 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 and2002, and is budgeted to increase a further 70% in 2003. However, it isalso shown that as a proportion of total government spending, publichealth expenditures have remained relatively constant at between 2 and3%. Similarly, government spending on health has remained at lessthan 1% of GDP. Both in absolute and relative terms at perhapsUS$4 per capita and under or around 1% of GDP government healthspending in Sudan ranks among the lowest in the world.

Percentage Expenditure on Different Types of ServicesHowever, total health expenditures seem to be considerably

higher. Along with decentralization, reforms in the mid-1990s includeda national health insurance scheme, institution of user fees at publicfacilities, and encouragement of private sector provision.

Out-of-pocket payments for health services are thereforeconsiderable, including significant expenditures by the well-off forcare abroad. Although no data are available on household healthspending, it is estimated that total out-of-pocket expenditures are largeor larger than total government health spending (that is, 1% or more ofGDP). In addition, the national health insurance scheme similarlyspends 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 percapita. This level would be consistent with the lower range of totalspending in countries in Sub-Saharan Africa.

Health spending in northern Sudan, however, seems to behighly skewed towards the better-off. Out-of-pocket payments, ofcourse, benefit the better-off more than the poor, while the insurancesystem covers only 8% of the population, mostly governmentemployees. At the same time, much government spending is focusedon hospitals, which tend to be used less by the poor.

Indeed, recent increases in government health spending seem tohave been devoted to a considerable extent to the development of

referral level facilities, leading to an unbalanced health systemfavoring hospitals and higher-level health cadres. While the

total number of primary health care facilities decreased slightly from6,413 in 1994 to6,184 in 2000, the number of general or rural hospitalsincreased from 162 to 200 and the number of tertiary-level hospitalsincreased from 78 to 109. Similarly, the number of medical schools hasexploded 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 marketsfor doctors in better-off urban areas of Sudan, but especially abroad, in

particular the Gulf countries. Of 16,000 physicians registered innorthern Sudan, only around 5,000 are working in the country.

Both markets will soon be saturated. At the same time, doctorsare reluctant to work in rural and peripheral areas, contributing to theregional disparities. Although the government has been working on itshuman resource challenges, in particular by elevating the status andresponsibilities of nurses, considerable work remains in strategydevelopment. For this, better understanding of market and individualincentives is essential.

Development of the private sector in recent years, encouraged bythe government, both supplied a market for (and is probably increasingly

being driven by) the enormous production of doctors. Private healthservices, concentrated mainly in urban and better-off rural areas ofnorthern Sudan, are perceived to be of better quality than governmentservices, and tend to be accessed more by the better-off. In Khartoum, anincreasing 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 gapsin coverage of the government system and serving populations whichare not attractive markets for private providers, such as IDPs. InKhartoum, for example, the number of NGO health centers (114) iscomparable to the number of government centers (118)

Health System PerformanceAvailability, Utilization, and Quality of Services

Coverage of basic services in many areas is low, sometimesextremely low. As noted above, measles immunization coverage in1999-2000 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 regionaldisparities in service availability and utilization. For example, a 2000survey in northern Sudan found that 61% of under-5 children withreported fever in urban areas were treated with anti-malarialmedication, compared to 42% in rural areas. Coverage of skilleddelivery 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 morelikely 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 togeographic access as much as to household economic status. The better-off are more likely to seek treatment at a health facility, while the poorerare more likely to go to traditional healers or not seek treatment.

Key Public Health ProgramsA number of key public health programs are important to healthsystem performance. For the most part, key vertical programs in bothnorthern and southern Sudan currently have limited coverage, awaitingGlobal Fund financing before scaling-up.

Immunization: Coverage is low in many areas, in particular insouthern Sudan, and is greatly dependent on externally-financedcampaigns.

Malaria control: Programs in northern Sudan have traditionallyemphasized vector control and are now focusing resources onlarger urban areas. Malaria programs in peripheral areas ofnorthern Sudan and in southern Sudan are limited to sporadic

preventive interventions, such as ITN distribution, as well asroutine curative care at health facilities.

Tuberculosis control: The national TB program in northern Sudanhas had success in recent years in expanding coverage of DOTS,although only 40% of estimated cases are detected. In southernSudan, 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 deliverycare in northern Sudan is relatively high, due to a long-standingemphasis on training village midwives, but extremely low insouthern Sudan. The effectiveness of delivery care in preventingmaternal 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 servicesare in place in many areas. In southern Sudan, it is known thatsuch 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 mortalitydata. The estimates are based on a combination of country life tables,cause of death models, regional cause of death patterns, and WHO andUNAIDS (United Nations AIDS) program estimates for some majorcauses of death (not including NCDs).The 10 leading diseases treated in health units for children age (0-4

years) in 2010

1-

Pneumonia2- Malaria3- Diarrhea& E.G4- Diseases of respiratory system5- Acute tonsillitis6- Acute bronchitis7- Disorders of eye8- Amoebiasis9- Injuries involving multiple body regions10-Disorder of ear & mastoidLeading causes of hospital admissions in 2010

C\S (4)D&GE (3)MalariaPneum(2)NVDS (1)5.6%6.4%10.1%11.3%11.4%anemiaabscessDM (6)asthmaOBS&GYN(5)1.8%1.9%2.2%3.1%4.2%

1- Normal vaginal delivery 2- pneumonia 3- diarrhea and gastroenteritis4- caesarian section 5- obstetrics and gynecology 6- diabetes mellitus


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Leading causes of hospital deaths in 2010% deathDeathsDisease

71616Septicemia5.51277Pneumonia

5.21192Other heart diseases

51163Circulatory disorders

4.41023Malaria

4.1946HEART FAILURE

4.1945Acute renal failure

3.9909M. Neoplasms

3.7949Malnutrition

2.6607DM

45.510527Total 10 deaths

54.512603Other diseases

10023130Total deaths


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Health Facilities:

The primary Health Care Centers (PHC) in Sudan are 6177.

Number of hospitalsState

27Northern

33R. Nile

16Red Sea

28Gadarief

16Kassala

49Khartoum

66Gazeria

25Sinnar

29W. Nile

17B. Nile

28North Kordofan

19South Kordofan

20North Darfour

6West Darfour

17South Darfour

438Sudan


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HUMAN RESOURCES FOR HEALTHThe primary concern in terms of human resources for health is to

match the needs of the countrys health system as it is beingrehabilitated, reconstructed and reformed. The declaration of theGovernment to upgrade nursing and allied health personnel training to

post-secondary diplomas and Masters Programmes will continue to bepursued by authorities at relevant levels to match these needs.

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 9nursing 9dentistry 10pharmacy 17Medical 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 complcatedchallenges, 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 system2. 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

geographyand 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. Encouragement of health programs that enhance theimprovement of health care awareness and delivery;

ii. Post graduate programs and researches should be supported;iii. We should know and feel the health problems that are

facing all African people which mainly are related topoverty and manpower;

iv. Possibilities for public/private partnerships should beexplored associated with studies on the nature and quality of

service effectively provided in public and private facilities.

References:

1- Sudan federal ministry of health report of 20102-

WHO Sudan health report

amsa-iua: conference proceedings_jan 2013-12. sudan

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