Impact of COVID-19 on continuity of health services
The spread of COVID-19 is affecting Sudan’s health care system, which had been under extreme stress prior to the pandemic. The system is straining to find the resources necessary to prevent, contain and treat COVID-19. Decades of inadequate investment, underfunding, poor infrastructure, limited qualified staff, poor equipment, insufficient medicines and supplies has weakened the system’s ability to respond to increased demands brought about by COVID-19 and other emergencies. The surveillance system does not cover the entire country and needs strengthening with long delays between alert and confirmation of an outbreak.
Against this backdrop, health partners are operating in an environment where approximately 81 per cent of the population does not have access to a functional health centre within two hours walk from their home. These access gaps are a critical impediment to the fight against COVID-19, as well as people’s general well-being and survival from other risks and threats.
Disruptions in services has been reported across the states due to closure of private health facilities as part of mitigation measures against the spread of COVID-19. Routine services in hospitals and other health facilities has been affected due to sporadic closures post confirmation of COVID cases and unavailability of medical staff.
According to the 2018 Annual Health Statistics Report (AHSR) from the Federal Ministry of Health (FMoH), there were 6,199 health facilities across Sudan, of which 260 were closed and not functioning prior to the pandemic. Of the working 5,939 health facilities, 523 were hospitals, 2,630 health centres, and 2,786 basic health units (for more information, please see the Sudan Health Facilities map link here).
Impact on health services in Khartoum State
Meanwhile, in Khartoum State about 70 per cent of Health Centres (HCs) were closed since May as a COVID-19 containment measure. The authorities in Khartoum State (the epicentre of the COVID-19 epidemic in Sudan) developed a plan to ensure continuity of health service in 70 functioning HCs during the lockdown period covering its seven localities.
At the functioning 70 HCs, the priority services include clinical services; laboratory; minor surgical theatre, short stay ward; EPI; nutrition; antenatal care and mobile clinics (in remote rural areas). Moreover, immunization services will be maintained in all health facilities, except hospitals. Khartoum State Ministry of Health (SMoH) is planning to re-open 39 HCs to increase the number to 109.
In rural areas of Khartoum State where the health services are provided mainly by basic health units (shafakhanas), the impact of lockdown and other containment measures on service provision might not be as significant compared to urban areas as most of the health workers are residing in the same villages. However, sustaining the medical supply system could be a challenge, particularly due to fuel shortages and other constraints as a result of the current economic downturn.
Impact on disease surveillance and Expanded Program on Immunization (EPI)
While routine services continue to be offered in functional health centres, the polio program supplementary immunization activities (SIAs) that target children under the age of 15 across Sudan have been suspended throughout the second half of 2020. In addition, due to lack of fuel, mobility difficulties, and lack of means of transportation as well as movement restrictions collected samples are kept at state level.
Containment measures continue to impact the Acute Flaccid Paralysis (AFP) surveillance. Sudan country program reported 40 new AFP cases during the week that ended on 21 June. Samples (40 cases + 10 contacts) are kept in the states. This brings total reported AFP cases since the beginning of the year to 159. The reported AFP cases are lower compared to the same period in 2019. Immediate notifications for the cases were received via email, but the investigation forms and stool samples (90) are kept in states’ cold chains.
The Public Health Laboratory (PHL) is operational and the World Health Organization (WHO) provided the PHL with high-quality internet access to avoid delays in reporting and to ensure better timeliness of AFP and environmental surveillance reports. In Khartoum, the lockdown affected active search, specimen transportation, and regular reporting.
By 21 June, about 670,000 cases of malaria were reported across Sudan breaching the epidemic threshold in six states –Blue Nile, East Darfur, Sennar, South Darfur, West Kordofan and White Nile. The malaria medication received during the month of April through the Global Fund to Fight Malaria, TB and HIV/AIDS program has not been distributed to the states due to logistical difficulties faced.
For measles, surveillance activities have been affected by the lockdown. The reporting of suspected measles cases is continuing, but no laboratory confirmation is available. The total suspected cases of measles reached 468 cases, with Kassala state reporting the majority of cases.
With regards to vaccinations, the coverage of Penta 3 and MCV1 vaccines is showing 9 per cent reduction compared to last year. About 112,000 infants expected to be vaccinated with Penta3 through March 2020 missed their vaccination.
Impact on non-communicable diseases and availability of medicines
Distribution of medical supplies across the states by the national medical supply fund and national health insurance fund has been affected by restriction of movements and difficulties to import necessary supplies.
Reportedly, only 15 per cent of the essential medicines and medical supplies are available in the market. Since 2017, Sudan has been facing challenges with ensuring adequate medicine and medical supplies as a result of economic crisis and hard currency shortages. In 2019, Sudan’s medicine imports were 20 per cent less compared to 2017 (Q4 2019 update CBoS). This results in lower availability of medicines in both government and private sectors compared to previous years, according to the FMoH and the WHO.
Impact on maternal and child health
The overall situation prior to COVID-19 was characterized by limited coverage of essential services as well as lifesaving emergency obstetric and neonatal care services (EmONC). The coverage of EmONC services is estimated at 32 per cent of the recommended. Khartoum state, the epicentre of the epidemic, there is a 69 per cent gap in available services.
For the Integrated Management of Childhood Illness (IMCI), most of activities planned for the first quarter were cancelled and increased transportation costs affected the provision of child health kits and supplies. ICCM volunteers were not able to implement community case management activities to most of hard to reach population as a result of lockdown and movement restrictions. As a result, a reduction in coverage is observed for IMCI in UNICEF target localities and states.
Referral services were also affected by COVID-19, creating significant gaps. FMoH held frequent consultations at both public and private health facilities to explore the gaps and advocate for resuming the service with precautionary measures in place.
Impact on lifesaving nutrition services
Nutrition lifesaving services are maintained in line with COVID-19 prevention measures mentioned in the “Nutrition sector operational guidance on Community Management of Acute Malnutrition (CMAM) and Infant and Young Child Feeding (IYCF) during Covid-19” to minimize the spread of the virus and ensure the safety of the nutrition workers and communities.
An overall reduction in the number of individuals seeking service is reported due to physical distancing and lockdown-related measures. Initial indications from the data received from the field show reduced cases of SAM treatment in the stabilization centres. It is anticipated that this will be further exacerbated by the current COVID-19 pandemic, which puts malnourished children at a higher risk of mortality.