COUNTRY Sudan’s mental health service: PROFILE challenges and future horizons Abdelgadir H. M. Osman,1 Aisha Bakhiet,2 Samia Elmusharaf,2 Abdelaziz Omer2 and Abdalla Abdelrahman2 1FRCPsych, Associate Professor, Sudan is located to the south of Egypt, along the concentrated in Khartoum, the capital city, Department of Psychiatry, Faculty of Medicine, PO Box 102, Red Sea. The country has a total area of where there are six psychiatric hospitals, two of University of Khartoum, 1 886 068 km2 (728 215 square miles) and a popu- which provide specialised services for forensic Khartoum, Sudan. Email: abdel- fi [email protected] lation of just over 37 million and is classi ed by the patients. Another is for drug and alcohol rehabili- 2Senior Lecturer, Department of World Bank as a low-income country. The adult tation, and is run by a quasi-governmental body, Psychiatry, Faculty of Medicine, literacy rate is 59%. The total annual expenditure requiring fees for the use of its service. Out of University of Khartoum, Sudan on healthcare is 4.3% of the gross domestic prod- the 18 federal states, only 12 have fully equipped fi Conflicts of interest: None. uct, but the proportion spent on mental healthcare psychiatric hospitals run by quali ed consultant is unknown. As of 2009, there were just 0.09 psy- psychiatrists. The other six are either managed Keywords. Transcultural psych- chiatrists and 0.2 psychiatric nurses per 100 000 by non-specialist medical doctors or by clinical iatry; low- and middle-income countries; history of psychiatry. population, and 0.2 mental health beds per psychologists and medical assistants. 10 000 people, of which 90% were hospital-based; Table 1 gives updated figures from the Ministry First received 14 Nov 2018 the other 10% were community-based units run of Health. The total number of mental health pro- Final revision 20 Jun 2019 1,2 Accepted 30 Jul 2019 by physician assistants and psychologists. fessionals working in all sectors, including the pri- vate sector and services run by non-governmental doi:10.1192/bji.2019.19 Mental health policy organisations (NGOs), is 899. Of these, 554 ’ (61.5%) work in formally constituted mental health © The Authors 2019. This is an Sudan s mental health policy, which was last pub- Open Access article, distributed lished in 2008, proposes the following components: units and hospitals; 350 of these individuals are under the terms of the Creative doctors who are either in psychiatric training Commons Attribution licence developing a mental health component in primary (http://creativecommons.org/ healthcare, scaling up human resources, involve- schemes or non-specialist doctors who run pri- licenses/by/4.0/), which permits mary care centres and associated units. Young unrestricted re-use, distribution, ment of patients and their families, strengthening and reproduction in any medium, advocacy, promotion of the human rights protec- doctors often move jobs to further their careers provided the original work is tion of patients, equity and access to mental health- and ambitions, and psychiatrists in training may properly cited. fi care services across different groups, quality not stay in the country. The workforce gures improvement, financing and monitoring systems. hide massive regional inequities; only a small pro- The publication of this national policy and strategy portion of psychiatrists work in rural areas, which ’ was followed by another document in 2009, pro- are home to two-thirds of Sudan s population. posing restructuring the mental healthcare system in the country. The drafting of these documents Prevalence of psychiatric disorders attracted considerable participation by leading Although no national prevalence study has been psychiatrists working in Sudan, as well as technical conducted across the whole country, many articles support from the World Health Organization fi 3,4 have been published addressing the psychiatric (WHO) regional of ce. needs of specific sectors or groups. These include schoolchildren, perinatal care, internally dis- Legislation and the Mental Health Act placed persons, out-patients and community Although a Mental Health Act was drafted in catchment areas. The following are indicative 1998, Parliament approved it only in June 2018. examples of findings from published prevalence The Act features the following components: access studies. The prevalence of depression and anxiety to mental healthcare, including access to the least in high-school students in Khartoum State has restrictive care; the rights of mental health service been estimated to be 12%.6 The prevalence of patients, their families and other caregivers; com- perinatal psychiatric disorders in primary care petency, capacity and guardianship issues for settings and communities in the capital city of people with mental illness; voluntary and invol- Sudan has been estimated at 23%.7 Higher rates untary treatment; appeal and review systems; of psychiatric disorders have been found among law enforcement and other judicial system issues internally displaced persons (53%),8 including 5 for people with mental illness. major depressive disorder (24.3%), generalised anxiety disorder (23.6%), social phobia (14.2%) Mental health set-up and workforce and post-traumatic stress disorder (12.3%). The Although mental healthcare services in Sudan are prevalence rate for major psychotic disorders theoretically free for patients, only those living in among the internally displaced population is – urban areas have access to out-patient clinics 1.5%;9 11 no data are available for suicide and can therefore be admitted to a psychiatric attempts, completed suicides, or drug and alcohol unit if required. Most psychiatric services are addiction. BJPSYCH INTERNATIONAL page 1 of 3 2019 1 Table 1 Mental health professionals in Sudan2,17 All in private and Profession public sector Public sector NGOs Private sector Per 100 000 Psychiatrists 81 48 2 31 0.21 Psychologists 262 65 37 160 0.69 Social workers 38 38 NK NK 0.16 Doctors in training 97 95 2 NK 0.20 Trained medical practitioners 345 255 3 1 0.91 Psychiatric nurses 76 71 0 5 0.2 Mental health staff only 554 317 7 2 1.6 NGOs, non-governmental organisations; NK, data not known. Mental health service provision (mhGAP)15 Intervention Guide.16 This scheme Access to mental health facilities is unevenly dis- aimed to train primary care physicians in the tributed across the country, being more available diagnosis and treatment of common psychiatric to those living in or near the capital city and, as disorders. Over 400 primary care doctors have emphasised, there are severe shortages of trained passed through the scheme to date. personnel. Many communities throughout Sudan use traditional and religious healers to help meet Scaling up mental health service their primary healthcare needs. Besides being in Sudan accessible and available, traditional healers are often part of the wider cultural belief system Researchers, policymakers and international and are considered integral to everyday life and agencies have issued calls for low- and middle- well-being. Attempts have been made to promote income countries to scale up the mental health a dialogue between mental health professionals components of their healthcare systems by cap- 2,17 and traditional healers. As a consequence, there acity building in the workforce. The WHO 15 are many traditional healing centres that embrace mhGap document recommended that Sudan integral working models of modern psychiatry needs least six mental healthcare workers per and receive regular input from medical assistants, 100 000 population. To accomplish this, Sudan who have participated in special training in mod- needs to greatly increase its mental health work- fi ern psychiatry, to provide diagnoses and force, from the current gure of just 1.6 per intervention.12,13 100 000 population, over the next decade. To achieve this, a new model of service delivery should be developed that delivers sustainable ser- Education and psychiatric training vices. This could involve training lay counsellors, Out of the 32 medical schools in Sudan, 17 psychologists, nurses and primary care doctors incorporate full psychiatric and behavioural sci- to provide early interventions at the grass roots, ence into their curriculum, including a clinical in urban and especially rural populations. skills-based component. Twenty-two teach psych- Academic departments and research units, iatry as a separate course and discipline, while the together with the policy-making department at other ten teach it as part of general medicine. the Ministry of Health in Sudan, should spear- Sudan trains over 3000 new doctors each year, head such changes, in collaboration with regional but most will emigrate within a few years.14 and international organisations. Postgraduate mental health training in Sudan started in 1990 under the oversight of the Faculty of Medicine at the University of References Khartoum (all postgraduate training is now over- 1 WHO & Ministry of Health, Khartoum (2009) WHO-AIMS Report on Mental Health System in Sudan. WHO. seen by the Sudan Medical Specialization Board). A clinical MD is offered, in a 4-year programme 2 WHO (2018) Mental Health: Strengthening our Response. WHO comprising examinations and a research-based (https:// www.who.int/en/news-room/fact-sheets/detail/mental- health-strengthening-our-response). Accessed 21 August 2019. thesis. So far, 178 graduates have qualified to become specialists in psychiatry, 75% of whom 3 Eaton J, McCay L, Semrau M, Chatterjee S, Baingana F, Araya have since emigrated, mostly to work in the Gulf R, et al (2011) Scale up of services for mental health in low- – States. In response, the Ministry of Health, income and middle-income countries. Lancet, 378, 1592 603. together with the Gezira University health pro- 4 Bruckner TA, Scheffler RM, Shen G, et al (2011) The mental gramme, with substantial support from the health workforce gap in low- and middle-income countries: a WHO local office, developed a novel scheme to needs-based approach.