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.

Health 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

• The vital statistics below include South Sudan.^[4]

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)

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 happenings, funds for health have been cut, adding to the fragility of the health sector.^[1]

• The health services are provided in addition to the ministries of health (federal, state and localities), by health sub-systems like insurance schemes, armed forces, and private providers. For provision of service, health care is organized at three levels: primary, secondary and tertiary level. The national health insurance fund, in addition to being an actor for financing, has its own health facilities. The armed forces and parastatal organizations like railways and Sudan Air etc. have their own network of health facilities and insurance schemes.

• The private sector, which is growing at a rapid pace, is concentrated in major cities and focuses on curative care.

• 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.^[5] 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 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][5][6]

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.^[7]

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.^[7] 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.^[8] 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.^[9]

Nodding disease

Nodding disease or nodding syndrome is a new, little-known disease which emerged in Sudan in the 1980s.^[10] 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.^[11] Sudan's HIV epidemiological situation is currently classified as a low epidemic, as of July 2011.^[12]

• Transmission

The main mode of transmission worldwide is through heterosexual contact, which is no different in Sudan.^[11] 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.^[13] 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.^[14] 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.^[11] Sudan is considered to be a country with an intermediate HIV and AIDS prevalence^[11] by the World Health Organization(WHO).^[15]

• 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.^[12]

• HIV/AIDS estimates as of 2014^[16]

HIV prevalence	53,000 [41,000 - 69,000]
Ages 15–49 prevalence rates	0.2% [0.2% - 0.3%]
Ages 15 and above living with HIV	49,000 [38,000 - 63,000]
Women aged 15 and above living with HIV	23,000 [18,000 - 29,000]
Ages 0–14 living with HIV	4,300 [3,600 - 5,200]
AIDS related deaths	2,900 [2,200 - 4,200]

Maternal and Child Healthcare

The 2013 maternal mortality rate per 100,000 births for Sudan is 2054. This is compared with 306.3 in 2008 and 592.6 in 1990. The under 5 mortality rate, per 1,000 births is 109 and the neonatal mortality as a percentage of under 5's mortality is 34. In Sudan the number of midwives per 1,000 live births is 1 and the lifetime risk of death for pregnant women 1 in 7.

Levels and trends in under-5 and infant mortality

• 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 deathsoccurring 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).
• 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).^[17]

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 ^[17]

Oral Health in Sudan

see also Dental public health , Outline of dentistry and oral health

Oral diseases are many, some of them are of public health importance . these are dental caries and periodontal diseases and oral cancer

Situation in Sudan

Little data are found in literature about the oral health in Sudan before 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.^[18] Dental services are included in insurance schemes with the exception of dentures, orthodontic treatments and plastic surgery.^[19]

DMFT and dmft

are indicators used to determine the status of dental caries. Here are some data for different age groups ^[18][20]

% 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,[18]
Age Group	DMFT	D	M	F	Year
12 years (Khartoum State) [21]	0.5	0.4	0.03	0.03	2007-08
16–24 years[22]	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 [23]	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

^[24]

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).^[25]

References

1. WHO (2014). "Sudan: WHO statistical profile" (PDF). Retrieved 11:32 am 6/9/2015. Check date values in: |access-date= (help)
2. Elsayed, Dya Edin Mohammed (July 2006, Vol.1 (3)). "National Framework for Ethics in Health Research Involving Human Subjects" (PDF). Sudanese Journal of Public Health. Check date values in: |date= (help)
3. WHO (May 2014). "Country Cooperation Strategy: Sudan" (PDF). Retrieved 11:50 am, 6/9/2015. Check date values in: |access-date= (help)
4. World Population Prospects: The 2010 Revision
5. Gaafar, Reem (June 2014). "Sudan Health System Financing review and recommendations" (PDF). The Evidence The Public Health Institute’s quarterly newsletter (10). Retrieved 6/9/2015. Check date values in: |access-date= (help)
6. WHO (2015). "Health systems financing review: What is OASIS".
7. "The burden of malaria in Sudan: incidence, mortality and disability – adjusted life – years". 2007.
8. "Yellow fever in Sudan - update" (Press release). The World Health Organization. 3 December 2013.
9. "Yellow fever in Sudan". World Health Organization. Retrieved 28 June 2015.
10. Lacey M (2003). "Nodding disease: mystery of southern Sudan". Lancet neurology 2 (12): 714. doi:10.1016/S1474-4422(03)00599-4. PMID 14649236.
11. UNAIDS, U., and WHO: assessment of the epidemiological situation. UNAIDS; 2004.
13. 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.
14. "Global Health Observatory Data Repository". Retrieved 14 January 2015.
15. WHO: summery country profile for HIV/AIDS. 2005. [cited 2007 13.10.2007]
17. Maternal & Child Health in Sudan by Paul Gubbins & Damien de Walque
18. EMRO - MALMÖ UNIVERSITY. "Oral Health Database".
19. WHO (2006). "Health Systems Profile- Sudan, Regional Health Systems Observatory- EMRO" (PDF).
20. 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.
21. 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 12:39 am 7/9/2015. Check date values in: |access-date= (help)
22. 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. Retrieved August 2015.
23. WHO Global Oral Databank - Niigata UNiversity. "Periodontal country Profiles".
24. EMRO- MALMO UNIVERSITY. "Oral Health Database". Retrieved August 2015.
25. 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.

External links

• World Health Organization (WHO): Sudan
• The State of the World's Midwifery - Sudan Country Profile
• Jasa sedot wc bekasi