Failing hospitals and private-public fiefdoms: what healthcare reveals about Sudan – By Nesrine Malik
The average hospital in Khartoum is a mix of disgrace and valour. With almost no resources, healthcare professionals swing between exhausted apathy and admirable personal sacrifice. In most hospitals in Khartoum, you will find doctors who both treat patients with callous indifference, as well as spend their very last penny in order to buy them lifesaving drugs.
Healthcare in Sudan was never without its problems, to say the least. Visiting a public health facility was always a case of potluck – whether they’d have the resources or whether you would find a doctor on duty that wasn’t stretched to their limit.
Private hospitals, although better equipped, were also not immune from the malaise of scarcity of resources and healthcare professionals. In a country where the gulf between rich and poor yawns wider everyday, top of the range healthcare in Sudan is still something even money can’t buy.
Things were always bad, but lately they have got very much worse. Healthcare in Sudan now is primarily a service industry with patients shouldering the cost for everything from injections to basic scans.
One of the first things that will probably happen when you are admitted to a hospital in Khartoum is that your relative is dispatched to purchase all the paraphernalia for your hospitalisation. Serums, oxygen tanks, new injections and needles. If you are lucky the hospital will have blood. If not you will have to procure that as well.
Most of these relatives simply do not have the money, they scramble around in a state of distress knowing that potentially the lives of their loved ones could depend on how quickly their procure these basic odds and ends. In some cases, doctors will simply empty their own pockets.
The main street in central Khartoum where the specialist doctors’ clinics are situated is well trodden by the sick who beg for help. They carry their subscriptions scribbled by the specialists who charged them the last of their money, and hobble from car to bystander to pedestrian, asking for help in paying for their medicine and scans.
The relative expense of basic medication in relation to the income levels of an increasingly impoverished class of low income Sudanese is crippling. Most travel to Khartoum for treatment from Sudan’s provinces, where healthcare is far worse, if that can be imagined.
In order to help, some doctors have resorted to social media, setting up Whatsapp groups and Facebook pages where they post urgent calls for funding or transport of patients, which other doctors and their associates then volunteer to fulfill. Al Hawadith Street Initiative, an entirely voluntary effort that donates life-saving resources to the sick, is a shining example of this.
But in many cases the number of doctors on a ward is just too small to accommodate the demand, and exhausted doctors with no clear line of supervision make serious mistakes. Some work up to 24 hours with no breaks or sleep.
In one case I witnessed in a Khartoum facility, a non-critical patient died overnight. The morning meeting to determine what happened was a limp exercise in buck-passing, with the supervising doctor mainly interested in what he could write as the cause of death, which was registered as heart failure.
A few weeks later, it was determined that the wrong medicine was administered, which caused the patient’s death. There was neither follow up nor accountability.
When I asked about the patient’s family, and whether they questioned the death, I was told that they were barely literate, and simply accepted the doctors’ word for it. They were not even comforted.
By all accounts these malpractices and micro-agressions against patients are common, and they are not always attributable to malice or inadequacy. There is a sense that all are trapped within a broken system. Loud arguments and physical attacks on doctors by desperate and frustrated patients and their families are increasingly common.
Registrars and House Officers are paid so poorly they might as well be full time volunteers. In 2010, a strike by doctors demanding better pay and working conditions led to arrests, detentions and even reports of torture.
In many cases doctors have no separate facilities or sterility privileges, sharing beds and toilets with the infectious. Many fall ill themselves.
This desperate state of affairs is down to combination of factors. One is lack of resources in general. Sudan is not a wealthy country, and this constrains all public provision in the country. (To be fair, even wealthy countries struggle to provide top notch healthcare.)
Long-standing economic sanctions have also severely impacted the country’s ability to run a functional, robust healthcare system, one that in African countries depends heavily on imported tools and technology.
The constant attrition of health professional numbers is another serious issue. Among the many Sudanese professionals seeking work abroad, Sudanese doctors are prominent, due to their employability in the Gulf and the easing of work visa requirements for doctors in the West.
Sudan has a huge brain drain problem in general – a house where there is not a single expat is a novelty in the country. This has hit the country hard, both in its intellectual white-collar capacities but also practically in terms of actual numbers on the ground.
Nowhere is this more evident than in medicine. IELTS courses are booked up weeks in advance as young doctors flock to pass language qualifications that will enable them to work in English-speaking countries.
If they do not pass, there is always the Gulf, where there is little scrutiny of medical degrees. Pre-specialisation Sudanese doctors are cheap, but still, in Sudan they would make a fraction of what they are paid in the Gulf.
Ironically, Sudan is a country where students flock to medical schools in their thousands every year. Previously the preserve of the highest achieving academically, medicine has now been opened to those with lower grades, but who can pay, in large amounts and in hard currency, through a mechanism known as “˜Private Acceptance’. This was sold as a way to combat the elitism and exclusivity of universities, but in effect was a way to privatize funding of public universities.
The faculty of medicine at the University of Khartoum was for a long time the only school in town, and is the alma mater of a golden generation of Sudanese doctors and the founding fathers of the medical sector in Sudan. In the past few years, the current government has deregulated the academic sector, both opening other public universities, and allowing private ones to open, diluting the University of Khartoum’s monopoly on a medical qualification.
Now doctors graduate from a plethora of sparsely resourced universities across Sudan. Yes this has provided more doctors, but many argue that it has simply produced more bad doctors – with those from the University of Khartoum still maintaining some vestigial reputation, although the university is not what it was.
Another reason for the recent downward spiral in healthcare provision is economic. The Sudanese post-secession economy is dysfunctional one, running in fits and starts, lurching from one fiscal cliff to the next.
Lately Sudan has been severely constrained in its financial affairs as banking sanctions have been further tightened. This has reduced Sudanese diplomatic missions to sending messengers to Sudan to pick up sacks of cash to pay employees.
That is not to say there is no money, but its deployment is haphazard, its sources erratic and its official pipelines opaque. There is never a perfect balance when it comes to state spending, but to see the lavishness with which the central government spends on its own facilities, most recently the NCP’s extravagant annual party convention, in contrast to under-stocked hospitals with corridors lined with patients waiting for beds, is to realise that something is deeply wrong with how the Sudanese state values the lives of its citizens.
The healthcare strategy and resource allocation changes in Khartoum in recent times have been down to one Dr Mamoun Humeida – Minister of Health for Khartoum, and a wealthy pioneer of private medical schooling and healthcare in the country.
A controversial figure with a superior, haughty air, and a simultaneously uncouth, unsophisticated demeanor, Mamoun Humedia spearheaded a privatization and resource re-distribution effort in the country. Widely regarded as rash and unstudied in his approach, he has been accused of closing major hospitals before opening others that could replace them.
Often seen on TV launching another state of the art facility that never seems to materialize, he has established a reputation for being dismissive and patronizing of the concerns of the people and is prickly and litigious when challenged, recently taking a newspaper to court for defamation. In what can be seen as a gross conflict of interest, he is also the owner of private hospitals, which are in direct competition with public facilities.
His most disastrous move was to close the Emergency Room at a major children’s hospital in Khartoum, claiming that this was to ensure that patients went to hospitals closer to their homes. Hearing this one would think that Khartoum had an ER department on every street corner, rather than a handful across the entire city.
Doctors say this was catastrophic for child emergency care, as the other ERs to which the cases were directed did not have the same facilities and were few and far between. Humeida’s support for privatization and a de-centralisation of medical care is typical of the way government public spending is run in the country.
Many spending policies are made under benign banners such as efficiency and re-distribution. But they are in effect furtive shimmies that allow the government to lift subsidies, spend less on public services, and to plunder them when needed, selling off land or property, or simply cutting off spending altogether, and passing the cost on to the citizen.
Mamoun Humeida is a problematic figure who exemplifies the new shape of power in the country – the businessman politician: a sort of private-public mix of commercial heft and government loyalty who blurs the lines between the personal and public purse. Promoting his own interests, as well as the government’s need to privatize, because of its lack of funds.
In a country that is increasingly cash-strapped, there is also a staggering of economic needs. At the top is the president Omar el Bashir’s and the National Congress Party’s immediate requirements.
el Bashir, in order to consolidate his position in an environment of constant rebellion both inside his party and among a restive populace, has over time created a huge patronage network. It needs continuous oiling in order to preserve the fragile mix of business, military, and security apparatus interests that supports his government. Running an oppressive non-consensus state is an expensive business.
There is little accountability and even less transparency. What little money there is, nowadays sometimes borrowed from benefactors in the Gulf, is diverted in many different directions before it reaches public services like education and health.
There is an increasing feeling, in Khartoum at least, as the seat of power, that it is a fiefdom. Even when the money is allocated to the health system, in many cases it evaporates before it reaches its destination due to corruption, mismanagement, and inevitably, a lack of healthcare managerial staff to shepherd it to where it is needed.
The overall impression is that of a system functioning not only without the help of the state, but in spite of it. Like with so many other aspects of life in Sudan, it limps along due to a combination of individual autonomous effort, and a little bit of help from your friends and family.
In the same way that Sudanese install electric pumps in their houses to draw the water out of the reluctant pipes into their homes, cobble together a functioning informal banking system via money transfers through mobile phones, and manage to keep the wolf from the door in the face of skyrocketing food and petrol prices by clubbing together and pooling resources – they are keeping a semblance of a healthcare system going.
It is both sad and reassuring, that the Sudanese who have had to depend on their own survival skills for so long, continue to do so in order to provide basic medical care for themselves and each other, wearily accepting the disinterest at best, and malice at worst, of their own governments.
Nesrine Malik is a columnist and political analyst based in London. She is reachable at @NesrineMalik
Thank you for this essay. It reflects so well the depressing and deadly state of health care in Sudan where, despite the huge expansion of medical education, the problems of the health system get worse and worse. The “disconnect” between the often valiant efforts of the Ministry of Health to establish good public health policies and standards and to focus on primary health care improvements and the actual reality on the ground is remarkable. Why? Funding is an important aspect, yes, but the politicization of healthcare is also devastating. Decisions about what facilities to open or close seem arbitrary or worse. The current situation of Khartoum Teaching Hospital right now is a good example. The staff have been protesting its planned closure for months and many have been arrested, harassed and some have even left the country to protect themselves.
The use of private hospitals has offered those who can afford it an alternative to poorly funded public clinics. There is now a two tier system in which kidney transplants are common but basic treatment for illness is not available for many. The rapid increase in inequality among Sudanese overall is reflected in the access to healthcare.
The higher education policies which have led to the opening of 36 medical schools have resulted in a huge number of doctors being trained but many are very badly trained. And many remain unemployed even as the health care system is in high need. Another example of poor coordination between higher education planning and health planning is that in Sudan more doctors are trained than nurses. There is an acute shortage of nurses and midwives and an excess of doctors. No wonder Sudanese doctors have become an export industry. Over 8000 left the country in 2013 alone.
Sudanese doctors and medical specialists once had the reputation as being among the finest in the world. Still one finds many practicing in the UK and heading so many facilities and medical faculties in the region.
But this reputation is also changing due to the proliferation of substandard medical schools.
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