Sudan's national mental health programme and burden of mental illness.

Sudan occupies 2 500 000 km2 in East Africa. It has borders with nine countries, two of which are Arab: Egypt, Libya, Kenya, Uganda, Congo, Chad, the Central African Republic, Ethiopia and Eritrea. Sudan is the largest country in Africa. The heart of the country, in terms of population, lies at the confluence of the Blue and White Niles. The complex of the 'three towns', comprising the three largest cities, Khartoum, Khartoum North and Omdurman, is situated there and contains almost 20% of the population. The total population of Sudan is about 35.4 million (projected from the 2005 census). The urban population was estimated at 33% of the total. About 2.2 million are still entirely nomadic. Sudan's peoples are as diverse as its geography. There are 19 major ethnic groups and 597 subgroups.

The Sudanese population is very young, with 43.1% below the age of 15 years and only 2.7% above the age of 65 (1994 figures). In 2000, the total adult literacy rate and the female adult literacy rate were estimated at 50% and 49% respectively. The crude annual death rate is 11.5 per 1000 population and the crude birth rate is 37.8 per 1000 population (2004). The infant mortality rate is estimated at 68 per 1000 live births, and the under-5 mortality rate is 104 per 1000 live births. Total life expectancy at birth was 56.6 years in 2000. The maternal mortality rate is estimated at 50.9 per 10 000 live births (2000).

Widespread poverty and the erosion of household coping capacities due to war make a large segment of the population vulnerable to food insecurity brought on by crises such as flooding, drought, conflict and displacement. Regional and urban/rural disparities in economic resources have clear implications for health and nutrition as well as service provision.

Psychiatry in Sudan began in the 1950s under the guidance of the late Professor Tigani El Mahi, the father of African psychiatry. He pioneered, among other things, rural services and the open-door policy. His successor, Dr Taha A. Baasher, shouldered the responsibility and further extended services to the periphery.

The national mental health programme

Targets of the programme

The guiding principles are: close integration of essential mental healthcare with the general health system, and in particular the primary care setting; development of training programmes for health personnel at all levels of the health service; development of an appropriate referral system, with comprehensive recording of information; provision of essential drugs; and community involvement and close collaboration with other social sectors, agencies and organisations.

Progress

In 1990, a mental health unit in the Ministry of Health was established. There is now a mental health board, supported by the Sudanese Psychiatric Association, which acts as an advisory body to the Minister of Health. Decentralisation to district general hospitals occurred in the early 1960s, and has now been implemented at the primary care level. Training courses are available for undergraduates, psychiatric specialist trainees and medical officers.

Attention has been given to special groups such as migrants, vagrants, the elderly, refugees and the displaced, as well as uncared for children. School mental health has been incorporated into the Mental Health Programme. A list of essential drugs has been formulated.

Administrative and managerial issues

In view of the fact that in the past 2 years the number of states in the country has increased from 10 to 25, an essential priority in the plan of action is the establishment of mental health services in these new states. An important priority in this respect is logistics.

Human resources development

In the plan of action for the programme, training is the foremost priority. A 4-year postgraduate course leading to an MD in psychological medicine was initiated in 1989. The postgraduate training programme is a current priority.

Evaluation

Though efforts have been made to evaluate the implementation of the mental health programme, more systematic planning and follow-up are required.

Research

Mental health research in Sudan has a long history, including collaboration with the World Health Organization and other bodies.

Mental health policy

Sudan’s mental health policy was initially formulated in 1998. The components of the policy are advocacy, promotion, prevention, treatment and rehabilitation.

Substance misuse policy

The substance misuse policy was initially formulated in 1995.

National therapeutic drug policy

The national therapeutic drug policy, which includes a list of essential drugs, was formulated in 1970.

Mental health legislation

The most recent legislation is the Gezira Mental Health Law of 1998. Mental health is also the subject of one chapter of the Public Health Act of 1973, which was revised in 1985. A Mental Health Act has been drafted and has gone to parliament for approval.

Mental health financing

There are budget allocations for mental health, but details of expenditure on mental health are not available. The primary source of mental health financing is taxation. The country has disability benefits for persons with mental disorders.

Mental health facilities

Primary care

Treatment of severe mental disorders is not available at primary care level.

Traditional healers are often used for the provision of mental health services. In Sudan, a symbiotic working relationship has been developed with faith healers over more than 30 years, as part of community-based mental health programmes. There was a great deal of initial resistance from the faith healers, who saw mental health professionals as competitors, but a non-confrontational approach brought home the message that indeed there are areas, particularly cases of emotional disorder, where collaboration between the two is possible. Such collaboration has gradually been formalised in order to set up referral channels for people with mental and neurological illnesses, particularly psychoses and epilepsy.

There are no community care facilities for patients with mental disorders. Community care is absent due to the lack of transportation, lack of social workers and poor health education.

Psychiatric beds and professionals

Many mental health professionals, including most psychiatrists, have left for other countries (World Health Organization, 2006). The numbers remaining are shown in Table 1.

Table 1

Numbers of beds and mental health professionals in Sudan

	National provision
Numbers of psychiatric beds per 10 000 population
Total number of psychiatric beds	0.20
of which in mental hospitals	0.18
of which in general hospitals	0.02
Psychiatric beds in other settings	0
Numbers of professionals per 100 000 population
Psychiatrists	0.09
Neurosurgeons	0.007
Psychiatric nurses	0.2
Neurologists	0.014
Psychologists	0.17
Social workers	0.1

The burden of mental illness

Total numbers of patients, by diagnosis and gender, for both 2005 and 2006, are given in Table 2.

Table 2

Patient numbers in Sudan, 2005 and 2006, by gender and diagnosis

	Male	Female	Total
Total numbers of patients discharged
Schizophrenia
2005	530	308	838
2006	1175	788	1963
Other psychosis
2005	867	718	1585
2006	1575	1237	2812
Epilepsy
2005	505	334	831
2006	564	825	1419
Out-patient attendance
Schizophrenia
2005	3157	2072	5229
2006	4136	2739	6875
Other psychosis
2005	4331	4342	8673
2006	10134	9525	19659
Epilepsy
2005	2812	2204	5016
2006	4357	3682	8039