Edward Thomas
Before war broke out in April 2023, Sudan’s health system reflected the country’s spatial and social inequalities. It was overwhelmingly dominated by the hospital and other curative healthcare services in and around the capital, with almost no resources for primary healthcare, or for healthcare in the country’s vast, diverse peripheries, where medical personnel and facilities were much fewer, and children died much more frequently. It was a mostly privatized system that treated healthcare as a scarce commodity rather than seeing public health as a social goal. This top-heavy system was decapitated in the first week of the conflict, and shattered fragments of the old system are taking its place – military hospitals, emergency rooms providing free care with the backing of revolutionary volunteers, private provincial hospitals trying to maintain their business model when medical supply lines have collapsed, public provincial hospitals financed by user fees, and whole cities cut off by war, where healthcare is not functioning at all.
Health services were spread out very unevenly across the country – reflecting a system of spatial inequality that was a key to colonial control and merchants’ profits. Poor parts of the country supplied cheap labour, received little investment in health or other services – and were much more likely to witness their children dying in childhood. At the end of the colonial period, in 1956, Sudan’s first census found that infant mortality in places like Darfur and the southern provinces (present-day South Sudan) was much higher than it was across most of the northern Nile valley – the developed centre of the country where most profits flowed.
In the 1960s and 1970s, Sudanese governments began investing in health care in poor areas and child survival rates improved. But investment was not enough to reverse the huge spatial inequalities in healthcare outcomes. In 1973, Sudan’s second census found that the survival chances of children in Khartoum were about 20 per cent higher than children in Darfur (2) . In the 1980s, a child in Darfur was 50 percent more likely to die before her fifth birthday than a child in Khartoum (3). During the 1990s, child mortality rates actually rose.
Sudan had different health systems in poor and rich areas. Places like Darfur had few hospital beds, and hardly any doctors.
Patterns of disease were different too. National figures (from 2019) show that the country had a ‘double disease burden’ – people died from both communicable diseases (like tuberculosis or HIV) and non-communicable diseases that are associated with longer lifespans and greater wealth (like ischaemic heart disease or cancers). These national figures do not reflect spatial inequalities within the country. But in areas where many children are dying, infectious diseases and vaccine-preventable diseases are higher. In Darfur in 2012, for example, respiratory infections, diarrheal diseases and malaria were the leading causes of sickness in 2012 (5).
These patterns of death and disease reflect Sudan’s unequal health system. Overall, medical advances, and the simple interventions that made up the child survival revolution, were reducing death and sickness – but inequality was increasing. The health system reproduced that inequality – and inequality intensified Sudan’s long wars.
The old free healthcare system had tried to extend healthcare across the country in the 1960s and 1970s. But in the 1980s free healthcare began to be eroded. A continent-wide debt crisis swept away state investment in health care. In the 1990s, the government of former dictator Omer al-Bashir largely privatized the health system. Even when state provision existed, the state charged user fees. Health had been a social goal, but under Bashir’s authoritarian market system, it became a scarce commodity. User fees emptied out the cash reserves of poor families – and forced them to earn more cash. In places like Darfur, where many people still ate food they produced themselves, the need for cash pushed people to sell more of their produce and their labour. This process of pushing people towards markets increased profit rates for merchants and their allies in the state, security forces and militias.
Privatizing health care is a way of pushing people deeper into money and markets. From the 1980s, patients started paying for government health services, and in the 1990s, much of the health infrastructure was privatized. By then, the health system was almost entirely financed out of patients’ pockets. Its resources were concentrated in places where profits were highest: the capital and urban areas of the richest states of the country. High-profit areas of medicine were boosted too: the health system was focused almost entirely on curative medicine, and neglected primary care. It barely served poor people, or people in rural or conflict-affected areas.
How privatized was the health system? National Health Accounts, published in 2018, give a picture of the structure of healthcare. Private healthcare accounted for 69 percent of health revenues. Government health expenditure accounted for 24 percent of health revenues. Foreign donors accounted for under 7 percent of health revenues – most of these revenues were from global health funds which financed immunization and disease-specific programmes run by the health ministry (7).
The system was built around private profit, and it depended heavily on imports. Pharma imports accounted for 95 percent of pharma supply: in 2022, pharma imports totalled US$ 571 million – 5 percent of the entire import bill (9).
Sudan pays for pharma imports with dollars, and this means that every currency crisis reverberates across the health system. Ever since Sudan stopped exporting oil, its imports have cost much more than in exports. For example, in 2022, imports were worth 11.1 million dollars and exports were worth 4.3 billion dollars. The exports are almost entirely made up of gold, agricultural and livestock products, which are almost entirely produced by poor people from areas where child mortality is high. The imports – mostly food, fuel, medicines and manufactured goods like cars and fridges – are nearly all consumed by rich people from areas where child mortality is low. When there is a currency crisis, the government responds by devaluing the Sudanese pound – which makes Sudanese exports worth less, and Sudanese imports cost more. Poor people have to work harder to help rich people keep up their consumption. Pharma importers passed on the cost of importing to patients – retail pharma prices in Sudan are usually higher than they are in the UK (10).
A big currency crisis in 2016 led to a dramatic increases in the cost of pharma imports. In the past decade, private pharma imports made up three-quarters of total imports, and public sector imports (which are sold in public hospitals and health centres) made up less than a quarter. The currency crisis meant that the National Medical Supply Fund, responsible for public sector pharma imports, built up huge arrears with its suppliers, and that public health facilities were always short of medicine – pushing patients towards private suppliers (11).
THE POST-CONFLICT SYSTEM: REVENUE AND SUPPLY
Revenues
In 2018, over 69 percent of healthcare revenues were private, and well over 99 percent of private revenues came from household budgets. Financial, liquidity and production crises are likely to undermine the capacity of households to pay for healthcare and lead many private providers to withdraw from healthcare.
The financial crunch will also affect government-financed healthcare systems: the government only provides free healthcare to narrow groups, such as under-5s, and most government services are provided in exchange for user fees. National health accounts define out-of-pocket health expenditures in terms of direct payments to health providers: including transport costs and wage sacrifices gives a picture of real costs, which according to one recent West Darfur study, varies from 15 to 40 percent of annual household income in households with no serious health problems – about US$ 250-600 per year, depending on location (12). These heavy cost burdens, and the stark differences between remoter and less remote locations, are likely to be increasing as a result of the conflict.
Government health revenues are collapsing, even in states with some revenue, such as Gedaref, the breadbasket of the country. On 2 August, the doctors’ union in Gedaref warned of the imminent collapse of the health service because accumulated non-payment of salaries was making it impossible for staff to continue working (13). El Obeid doctors were also reportedly planning to strike over working conditions.
Medical supplies
The catastrophic revenues situation will have significant consequences for medical supplies. Medical supplies are provided by both private and public sectors on a cost-recovery basis – a few groups, such as under-5s, are exempt. If households are not able to pay for medical supplies, this will affect the functioning of both systems. At the outset of the conflict, the NMSF was already wrongfooted. It used to distribute supplies to state warehouses on a quarterly basis. But the supplies due by end-March 2023 were delayed: only Red Sea state received supplies before the war began on 15 April.
The Professional Pharmacists Alliance (PPA) issued a statement on the medical situation on 30 July. It called on the finance ministry to allocate funds to funds to the NMSF, whose staff are working without salaries. It said that all regions are facing acute shortages of medicines for communicable and non-communicable diseases, and of basic supplies for blood transfusion and dialysis – to the extent that patients are deteriorating and suicides have been reported. Shortages are particularly acute in Khartoum, Darfur and Kordofan, where pharmacies and warehouses and convoys have been looted. Some Khartoum pharma stocks have been moved to neighbouring states, providing temporary alleviation of shortages – but the PPA does not expect this alleviation to last. It called on the public to bring any surplus medicines lying at home to pharmacies to help them deal with the current crisis.
A report by the government news agency SUNA on 1 Aug said that the ministry of health had issued a decree setting up an emergency NMSF centre in River Nile state, to supply medicines to Khartoum and Northern state. The acting federal health minister, during a visit to the centre, said that lists of required medicines to international donors, and he expected them to be delivered soon (14). The minister’s statement suggested that he does not expect the NMSF to finance imports any more. The PPA does not believe that the private sector will fill the gap. All private pharma factories have stopped operating. Some private importers are now importing a few essential medicines, but many have stopped because of the risks that warring parties may expropriate their goods.
There are already reports of expropriation of pharma, and diversion of donated pharma to markets. But illegal or grey-zone practices are not the biggest challenge. In its current state, Sudan can no longer afford its enormous, half-a-billion dollars pharma bill. The dollars that paid for these imports came from the Central Bank, which in turn got them from the proceeds of Sudan’s exports – mostly gold, agriculture and animal products, which were worth US$ 4.4 billion in 2022. These exports have all but dried up – meaning that it will be impossible for importers without independent supplies of dollars to bring in medicine. In July, the government news agency reported that Sudan had exported 294 kg of gold in the three-month period since the start of the conflict, about US$ 20 million’s worth – less than one percent of the value of gold exports in 2022.
Sudan’s economic crisis is likely to bring an end to the import-dependent, private-sector led health system and replace it with something different. There will be enormous competition to get hold of medical supplies, and many populations are likely to lose that competition. The PPA’s 31 July statement sketched out some of the groups likely to lose out.
The population of Darfur, Kordofan and Khartoum
Patients needing emergency medicines and blood transfusion
Patients with neuro-psychological disorders
Patients with chronic diseases such as hypertension or diabetes.
In addition, PPA members interviewed for this paper said that supplies of HIV and cancer medications – which before the conflict were limited because of the indebtedness of the NMSF – have dried up. Impoverished displaced patients are spending their savings on specialist pharma.
EMERGING HEALTH SYSTEMS
The spatial and social inequalities that were embedded in Sudan’s pre-conflict healthcare system have been deepened and complicated by the war. Different, traumatized health systems are emerging, and they are likely to reshape and deepen health inequalities. Emerging systems will play different roles in this major reorganization of health care. Five emerging systems are briefly discussed here:
Military medicine
Heroic, volunteer-based frontline medicine organized by decentralized revolutionary youth networks in urban conflict zones
Expanding, locally-financed healthcare facilities in less conflict-affected states near Khartoum, which are benefiting from massive outflows of medical personnel and resources from the capital
Traumatized and exhausted public facilities in the impoverished conflict zones of Darfur
Foreign-funded medicine, including facilities part-managed by medical humanitarian organizations, stymied by access restrictions.
Military medicine
As medical supplies dwindle, demand from the medical corps of the warring parties is increasing dramatically. At the start of the conflict, both main warring parties were accused of abducting doctors and expropriating medical supplies. It was an indication of the pressures on military medical systems: sources within both armies had privately let it be known that many army medics had been killed, particularly in Khartoum. It was also an indication that military medical needs are likely to trump civilian medical needs for some time – although some military hospitals provide civilian services (for example, the maternity section of the main military hospital in Omdurman offered obstetric services to civilians at the start of the conflict). Shortages of personnel and supplies are likely to lead to greater pressure from military actors on the health system, particularly in and around conflict areas – and on humanitarian medical supplies.
Emergency rooms
Emergency Rooms (ERs), mostly linked to neighbourhood Resistance Committees (RCs), are trying to keep facilities open and rationalize local medical supplies, often taking enormous risks in the process. They are providing a wide range of medical services, including provision of hospital fuel and food and medicine deliveries RCs are democratically organized revolutionary organizations, and their accountability mechanisms and understandings of vulnerability are in many respects superior to those of other structures. But they are often under attack by warring parties: many ERs have reported that attacks of facilities and abductions of members. Some areas in the capital have witnessed very severe fighting in the past few days, and extremes of violence may make it impossible for ERs to maintain services. ERs are being supported by Sudan’s large medical diaspora and also by some international organizations, but resources are mostly generated locally. The supply situation is very difficult – some are not able to maintain cold chain storage.
Hospitals and health centres in states neighbouring the capital
The government news agency has issued some good news stories about hospitals in less conflict-affected states to the north, south and east of the capital, where public and private hospitals are still operational: the first brain tumour operation in Shendi (River Nile state); the first open heart surgery in Merowe (Northern state); the psychiatric hospital in Wad Medani (Gezira state) which is now serving the entire country. Before the conflict, it was difficult for public hospitals in these states to attract doctors, because salaries were so low, and health authorities in several states have welcomed the influx of medical personnel from Khartoum. But now, hospitals in these areas have some ability to provide curative services for people with serious non-communicable diseases.
However, these good-news stories need to be seen in a wider context of increased demand from displaced populations, unprecedented supply shortages, and non-payment of salaries: Merowe hospital is having to serve a displaced population estimated at over 60,000 people end-July, and surgical and renal supplies have all but run out.
At the start of the conflict, state governments in less conflict-affected areas were able to mobilize some revenues for healthcare from insurance funds and elsewhere. Some benefited from transfers of equipment and supplies from hospitals and warehouses in the capital. However, this increase in supply is likely to be temporary. Private and public hospitals rely on user fees, and patients unable to pay are still refused treatment. The dramatic contraction in health supply is likely to lead to an increase in user fees.
If supplies increase in the future, health facilities in these less conflict-affected areas near the capital are best positioned to attract resources. Transport networks are functioning in these areas, and the Red Sea ports are more accessible.
Health systems in the conflict zones of Darfur
Ahmed Gouja, a journalist based in Nyala during the first months of the war, gave a vivid account of the health impacts of the war:
I have learnt that the impact of war is not just about death and destruction. It is about the damage it does to your sense of agency: the way it makes you feel powerless; the way it makes you feel like there is nothing that you can do to make things better. When my nephew was hit, we took him to a local hospital only to find that all of the doctors had fled and that they didn’t even have a bed for him to lie on. We sat for hours with a bandage trying to stem the blood. We felt totally helpless. Later in the day, we went to one of the few private hospitals that was still open, but they charged us thousands of dollars for surgery. We managed to raise the funds but other families that walked in with dying relatives did not (15).
By September, Nyala was cut off from outside communication and it is not even clear if such cruel dilemmas are still playing out in its hospitals. However, it is likely that hospital function has been affected by the collapse in financing for health care. Some doctors in Darfur have gone on strike because of non-payment of wages and lack of medical supplies, an indication of the extreme pressures that the health system is facing. Pharma and other medical supplies are very limited, and hospitals are on the front lines of confrontations between the two main warring parties and associated militias (16). This has compromised access for many patients, and although there is very little reporting of health conditions outside the cities, rural health care is likely to be very badly affected by the lack of supplies and also by the economic crisis. New displacements are disproportionately affecting Darfur: on 6 Aug, IOM estimated post-April 2023 displacements at 3.3 million people, a third of whom are in Darfur – whose population is roughly a quarter of the country’s total. People displaced from Khartoum are going to areas where health systems are marginally better protected from the current crisis: but Darfurians are being displaced to urban and peri-urban areas whose health systems have been totally traumatized.
For the NMSF and private pharma companies, it was a challenge to supply Darfur even before the current crisis. It is even harder to get supplies into the region since the latest conflict began. State governments in Darfur have historically been much less resourced than state governments nearer the capital, and reports of doctors’ strikes and widespread medical volunteering indicate that states are unable to meet health costs.
Foreign funded health care
Foreign-funded healthcare accounts for a very small proportion of current health expenditure. In 2018, revenue from foreign sources amounted to 6.6 percent of current health expenditure – around US$ 163 million. Much of that money came from private-public global funds, and most of it was spent on immunization, malaria control, TB and HIV. Bilateral assistance also played an important role. Bilateral medical assistance is continuing, but on a small scale: in the past month, Qatar announced that it opened a pharmacy in Wad Medani Teaching Hospital providing free drugs to about 300 IDP families, and China announced support for chronic disease and malaria medication in Red Sea state (17). Support from public-private global funds has also continued – particularly support for the Extended Programme of Immunization, which amounts to almost a third of foreign health funding. At the start of June, UNICEF airfreighted 20 tons of vaccines to Port Sudan; and the ministry of health took responsibility for distributing to the states. UNICEF procured two million doses of measles vaccines, and two million doses of polio vaccines in July, but financing for other major vaccines was not available, and a scheduled flight for end-July appears not to have gone ahead – according to one source, the lack of cold storage in Port Sudan customs may also be hindering vaccine imports. Although Sudan made significant progress in vaccination before the COVID-19 pandemic, ERs in conflict areas are reporting cold-chain breakdown. Access issues are likely to compromise immunization and other major foreign-funded programmes. The ability of the health ministry to supply all states is likely to diminish – and even if responsibility for administering the vaccine programme is passed to the UN, the enormous access challenges will remain.
CONCLUSION
New patterns of spatial and social inequality are emerging. Sudan’s spatial and social inequalities were deeply embedded in the pre-April health system. Emerging health systems will reflect old patterns of inequality and new ones – but new cost and disease inequalities will be much harder to monitor as surveillance systems break down.
In the 1970s, Sudan made progress on the primary health care agenda. But three decades of ferocious privatization and commodification subsequently produced a Khartoum-centred, privatized health system which provided very few services outside the capital. Even though a network of teaching hospitals was built across the country after the 1990s, these hospitals were never able to mobilize resources or staff. Foreign-funded health care has not always helped. The global funds, with their focus on high-profile killer diseases, were implicated in the decline of primary healthcare provision and the rise of paid-for healthcare.
The burdens of communicable and non-communicable disease are likely to increase everywhere, but access to treatments will be concentrated in less conflict-affected areas with relatively easy access to the port – and for people with the right military connections. Health systems are likely to disintegrate at a slower pace in less-conflict affected areas around the capital – where epidemiological transitions towards non-communicable disease were more advanced. But all areas are likely to endure an intensified double burden of disease. Children are likely to be disproportionately affected by the heavier burdens: vaccine-preventable diseases are likely to rise in inaccessible populations numbering in the millions, further skewing burdens and access.
All these processes are likely to lead to deeper fragmentation of the health system. Military medicine may divert resources away from the general population, and make access to some health procedures dependent on security connections as well as money. Functioning hospital and health centres are likely intensify the commodification of healthcare.
But in Sudan there is always hope. The model of healthcare pioneered by the ERs presents an attractively idealistic but fragile template for future healthcare: decommodified services provided on the basis of need, with needs and vulnerabilities determined through democratic processes, rather than by state or market diktat. But ERs also face many risks, not least because of their connections with RCs, which constitute a new kind of political force in Sudan. Youth-led, decentralized, democratic and revolutionary, the RCs have been at the forefront of demands for a new healthcare system that reflects democratic rather than market values. The RCs still represent the most potent form of civic resistance to both warring parties, and although both parties share an interest in neutralizing them, these revolutionary youth networks are still managing to survive.
Edward Thomas has worked in Sudan and South Sudan as a teacher, human rights worker and researcher for over 15 years.
*This is an original piece written exclusively for PeaceofSudan.Space and has not been published elsewhere.