Failing Hospitals and Private-Public Fiefdoms - What Healthcare Reveals
About Sudan
By Nesrine Malik
15 November 2014
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 _at_NesrineMalik