SUDAN COUNTRY REVIEW The number of people living with diabetes in Sudan remains an estimate, but strengthening of the health care system helps getting a clearer picture of the situation.      Building a base for diabetes care in Sudan Similar to other African countries, diabetes is no longer rare in Sudan. The country's resource strained health care system is far from ready to deal with the rising burden of diabetes estimated to affect 3.3% of the country's 43 million inhabitants (1). This combined with a long history of internal conflict, the challenges and barriers are many when supporting diabetes projects in Sudan. Nevertheless, the World Diabetes Foundation decided to commence support in 2004 and the experience throughout eight projects to date has been overwhelmingly positive. "Not only do we see an excellent collaboration and understanding between different project partners; the projects also produce tangible results," says Programme Coordinator at the World Diabetes Foundation and responsible for projects in Sudan, Ms. Hanne Strandgaard. "Slowly but steadily, the story of support to the area of diabetes care in Sudan is turning into a story of partnerships and collaboration throughout the country involving different organisations and areas of diabetes care." The eight projects supported by the World Diabetes Foundation in Sudan are targeted to reach more than 400,000 people. "If we meet this target, it will be an impressive coverage of people living with diabetes in Sudan," says Ms. Hanne Strandgaard. "Considering that there is no national diabetes programme covering all of Sudan and considering that with funds from the World Diabetes Foundation alone, we are able to reach more than half of those living with diabetes, I am very positive about the impact our support may have," she says (2). ______________________________________________________________________________________________________ In the beginning - creating diabetes mini-clinics and units      Laying a base In the period from 2004 to 2009, the World Diabetes Foundation supported two initial diabetes projects in eight states of Sudan. These two projects have laid a sound foundation for extending diabetes care to more states and venture into secondary and tertiary levels of care. Both projects were anchored in the non-communicable diseases section under the Sudanese Federal Ministry of Health (FMoH). With an overall objective of improving the capacity of the Sudanese health care system to deliver, manage and monitor services for the prevention and treatment of diabetes, the two initial projects focused on training and establishing clinics. Primary care close to people During the course of these first projects, focus was shifted from secondary to primary care because a greater need was seen there. According to the former project responsible, Dr. Samia M. Hassan, "The primary health care system needed strengthening before secondary health care could become focus.   The eight states covered by the first three projects                             Our health system is not yet geared for secondary and tertiary care on a grand scale. What is needed is primary care close to people. Furthermore, we lack physicians for secondary health care and we currently do not have the capacity for specialised diabetes care," she said. At the successful completion of both projects, a total of 57 diabetes mini clinics and 14 diabetes units and centres had been established. Concurrently with the establishment of clinics, 180 doctors and 160 diabetes educators were trained. The collaboration with a variety of partners across sectors was characteristic for both projects and this set the standard for future projects. The World Health Organization, the private and public sectors as well as non-governmental organisations were all involved in the projects. "The successful inter-sectoral collaboration and networking between stakeholders has secured a strong sustainability and ownership. The programme will continue into an annual strategic plan for diabetes," says Professor Mohamed A. Eltom, former General Coordinator of the National Diabetes Programme under the Ministry of Health and responsible for two projects supported by the World Diabetes Foundation. Mobile care to satellite clinics Under a third project, the level of care in the Northern State was extended to also include tertiary care. In practice, the diabetes centre in the state capital, Dongola was upgraded to a tertiary referral centre and has become a centre of excellence for treatment as well as for training of medical students. A mobile diabetes clinic forms part of the project and conducts monthly visits to satellite diabetes clinics in the Northern State. Read about the projects: WDF03-061/06-181/06-164 _________________________________________________________________________________________ Diabetes children's programmes Being a child with diabetes in Sudan Life expectancy for a child with diabetes is very low in most African countries. This is due to factors such as low health care personnel capacity, cost of care, limited availability of insulin as well as monitoring equipment. According to the latest International Diabetes Federation Diabetes Atlas, the incidence of type 1 diabetes in children in Sudan is 10/100,000 population which is at the high end in an African context. The World Diabetes Foundation has granted support to two childhood diabetes programmes in Sudan. The first project, Integrated Management of Diabetes in Children (IMDC) ran from 2007 to 2009 and was based in the Gezira State; the second is based at the Jabir Abu-Eliz Diabetic Centre in Khartoum and will run from 2009 to 2011 and cover almost the entire country. The children's programmes are further examples of the success of one project laying the base for extending the elements into a broader project - building on the experience gained in the initial project. The 14 states covered by the childhood projects Better prospects for life As the childhood diabetes clinic in Gezira was strengthened under the first project, the number of children registered grew from 40 to over 700. Similarly in Khartoum, the number of children with diabetes registered has grown since 2005 when a group of voluntary doctors got involved and started building up the clinic to also focus on children. "The same way, we expect to gradually find more children with the establishment of initially 25 childhood diabetes clinics in 14 states," says project responsible Professor M.A. Abdullah from the Sudanese Childhood Diabetes Association. "The more children with diabetes we identify, the better we can care for them and improve their quality and prospects for life," he says. Read about the childhoos diabetes projects: (WDF06-167 / 08-369) ________________________________________________________________________________________ The next steps - towards specialised care Reducing maternal mortality  Since 2007, the World Diabetes Foundation has supported a project focusing on gestational diabetes mellitus (GDM). The project is based at the Alhaq Yousif Reproductive Health Centre in Khartoum where Sudan's first operational GDM clinic has been established. While gestational diabetes is not the only reason for Sudan's high rates of maternal mortality, it is definitely a contributing factor (3). Project responsible, Dr. Siham A. Balla is well aware of this with an estimated 3% occurrence of GDM: "By early detection of GDM and by raising women's awareness about diabetes in general and GDM in particular, we increase the knowledge among pregnant women. GDM control and management along with periodic screenings are elements which contribute to reducing maternal mortality because the factors causing maternal mortality are manifold," she says. By training doctors and midwives in gestational diabetes protocols and educational material, the project has steadily been extended to seven diabetes mini clinics in the state of Khartoum beside Alhaq Yousif Reproductive Health Centre. These centres cover almost 1,500 pregnant women out of an estimated 78,000 pregnant women in Khartoum State, corresponding to 2% of the state population. "Once we evaluate the project and take the lessons learnt, we will expand the project to all of the 161 health centres in Khartoum and then replicate in other selected states of Sudan," Dr. Balla reassures. Read about the GDM project: WDF06-207 The beginning of diabetic eye services The Eye Care project builds on the previous project on Integrated Management of Diabetes in Children (IMDC). Although no prevalence for diabetic retinopathy exists in Sudan, the IMDC recommends conducting eye screening among children above the age of 12 and adults who have lived with diabetes for more than four years. Considering the fact that the majority of children with diabetes are having HbA1c-levels above 7.5%, it is realistic to expect that many children will have eye changes and will need attention earlier to prevent blindness and to improve their quality of life. The project is based at the Faculty of Medicine at the University of Gezira and collaborates with the Elsaim Eye Hospital in Wad Medani (Gezira State). The overall goal of this project is to help establish a national model and reference clinic for eye screening in Sudan. Currently, eye care services for people with diabetes only exist in the capital city, Khartoum. Read about the diabetic eye project WDF08-350 Extending care in Sudan: diabetic foot A diabetic foot project in Sudan was launched in late 2008 with the aim of reducing the high rates of major amputations due to diabetes. The Jabir Abu-Eliz Diabetic Centre located in Khartoum is the only centre of its kind in the country. Yet, with more than 600,000 people in Sudan currently suffering from diabetes, an urgent need exists to extend care outside the capital city. The project aims at establishing 20 diabetic foot clinics at existing health care facilities throughout Sudan. The method follows the known Step-by-Step model where multidisciplinary teams are trained in the field of diabetic foot care, including screening of high-risk patients, podiatry care, patient education, and wound dressing. Within the first year of implementation, five clinics have been established and 62 health care professionals trained. Presently, these clinics are catering for 30,000 patients with diabetes and with more than 6,500 patients suffering from diabetic foot complications. The 14 states covered by the diabetic foot care project  Project responsible, Prof. M. Elmakki Ahmed speaks with enthusiasm about the project: "Bringing screening for complications and high-quality care to patients in areas with limited access to health care will save thousands of lives, reduce the burden on health care budgets and enable us to help many more," he says. Read about the diabetic foot project WDF08-359 ________________________________________________________________________________________ D. The value of our investment Consensus among partners According to World Diabetes Foundation Programme Coordinator, Ms. Hanne Strandgaard, the main reason for success in the projects supported by the Foundation in Sudan is the strong collaboration between all partners involved. "The Ministry of Health plays a huge role - in collaboration with the different organisations we work with. They complement each other and cooperate well," she says. The Federal Ministry of Health has been involved in all projects, and this has ensured strong ownership of all diabetes initiatives as well as sustainability after the support from the World Diabetes Foundation ceases. According to Professor Mohamed A. Eltom, former Vice-President of the Sudanese Diabetes Association, a good base has been created for venturing into a nationwide diabetes programme: "Now that we have developed a system and laid down a formula, there is a level of integration between the different institutions and there is consensus among the partners and disciplines about the levels of care," he says. Step-wise capacity building Measuring the impact of the support to diabetes projects in Sudan so far is a complicated task because we operate in an area with very little data available. However, we do have tangible results for capacity building for number of clinics established and people trained.To date, 101 diabetes clinics and mini clinics have been established or strengthened; 389 doctors and nurses and 305 educators have been trained in detection and management of diabetes. With the gradual geographical expansion, 19 of Sudan's 26 states are currently covered by or planned to be covered by projects supported by the World Diabetes Foundation.    19 out of Sudan's 26 states are or will be covered by projects supported by the World Diabetes Foundation "In effect, these projects have demonstrated how the project partners have addressed diabetes care in a step-wise manner by first establishing diabetes care facilities in clinics, secondly upgrading these by empowering diabetes education of patients and health care professionals. Thirdly, the facilities have been further upgraded to include preventive care (secondary care) and treatment of complications (tertiary care). All along, the projects have had the full support from the Federal Ministry of Health, thereby ensuring long term sustainability. Despite soaring conflict and encompassing poverty in Sudan, I am therefore confident that these projects have made a considerable impact and will continue to do so in the future," Ms. Hanne Strandgaard concludes.     References 1. IDF Diabetes Atlas, 2009. According to UN World Population prospects (2008 revision), Sudan's population in 2010 is projected to be 43.192 million. 2. According to IDF Diabetes Atlas, 2009, 675,300 people live with diabetes in 2010. Local estimates, however, are higher. 3. UNFPA estimates five deaths per 100 live births in the North and 17 in the South - numbers which are linked to poor access to quality reproductive health services (UNFPA 2006 http://sudan.unfpa.org/docs/COAR%202006%20-%20Sudan%20CO1.pdf)

Back to Q4-09 main