As the war continues in Sudan, the health sector is experiencing an unprecedented crisis, with a shortage of medicines and health workers, and the targeting of health institutions by the Rapid Support Forces.
Since mid-April 2023, the Sudanese army, led by the President of the Transitional Sovereignty Council, Army Commander Abdel Fattah al-Burhan, and the Rapid Support Forces, led by Muhammad Hamdan Dagalo (Hemedti), have been waging a war that has left more than 20,000 dead and more than 14 million displaced and refugees, according to the United Nations. And local authorities, while research by American universities estimated the death toll at about 130,000.
The Sudan war broke out before the end of a political process based on the “Framework Agreement” signed on December 5, 2022 by the military component of the transitional authority at the time and civilian forces, most notably the “Freedom and Change – Central Council”, and the parties failed to resolve the issue of integrating rapid support within the military institution. .
Targeting rapid support for the health sector
Several reports indicate that the Rapid Support Forces have targeted health facilities in Sudan. For example, in December 2024, Doctors Without Borders said that the Rapid Support Forces targeted Bashaer Hospital, south of the Sudanese capital, Khartoum, by shooting its soldiers inside the hospital.
The international organization explained in a statement: “The attackers opened fire inside the emergency department, directly threatened the medical staff, and seriously disrupted life-saving care.”
She added: “We strongly condemn the violent incursion of the Rapid Support Forces into the emergency room of Bashayer Teaching Hospital in southern Khartoum” on Wednesday.
The organization called on the Rapid Support Forces to respect the neutrality of medical facilities and the safety of health care workers.
In the statement, the head of the MSF mission in Sudan, Samuel David Theodore, said: “Several RSF soldiers entered the emergency rooms and some of them began shooting at medical workers, threatening patients, MSF staff and the Ministry of Health.”
In August 2024, the Sudanese News Agency said that the Rapid Support Forces bombed Al-Dayat Hospital in Omdurman and its surrounding areas. The agency explained that a large number of shells fell in the area and caused widespread damage to buildings.
She pointed out that the Khartoum State Health Emergency Committee condemned the bombing and considered it further evidence of the support forces targeting health facilities and disrupting efforts to provide treatment services to citizens.
Mohamed Ibrahim, head of the committee and official spokesman for the Ministry of Health in Khartoum State, said that the support forces had previously extensively looted the equipment of Al-Dayat Hospital, which is the largest specialized hospital in the country.
Atrocities
A few days ago, the American newspaper The New York Times published evidence supported by video clips, collected by its visual investigations team, documenting atrocities that it said the Rapid Support Forces had committed in Sudan over a year and a half since the outbreak of war between them and the Sudanese army on April 15, 2023.
Visual evidence collected and analyzed by the American newspaper over a period of months reveals the identities of the leaders of the Rapid Support Forces, whose soldiers were committing “atrocities” under their watch throughout Sudan.
She said that this investigative investigation, documented with video footage, allowed her to identify 10 leaders of the Rapid Support Forces while they were supervising possible war crimes and to determine the locations of many of their other theaters of operations, noting that their supreme commander, Lieutenant General Mohamed Hamdan Daglo, known as Hemedti, is the one who may bear full responsibility. .
Insecurity
The World Health Organization says insecurity makes providing health care more difficult. More than two-thirds of the main hospitals in the affected areas are out of service, and those still operating are at risk of closure due to lack of medical staff, supplies, clean water and electricity. Repeated attacks on healthcare facilities prevent patients and health workers from reaching hospitals and receiving treatment, as health facilities, medical warehouses, transport of supplies and health workers are targeted. The disease surveillance system has also been disrupted, posing a serious challenge to detecting and confirming outbreaks of infectious diseases.
The organization adds – in a post on its website that was last updated on December 16, 2024 – that millions of people have been displaced since the beginning of the conflict, inside Sudan but also in neighboring countries, where people fled in search of safety, in Chad, the Central African Republic, Egypt and Ethiopia. And South Sudan.
The World Health Organization, in cooperation with its health partners, is working extensively to coordinate the health response and enhance care.
For its part, the International Committee of the Red Cross says that repeated attacks on health facilities and their workers have dire consequences in light of the worsening food crisis. Health care centers are crucial to preventing, detecting and treating malnutrition. Their ability to work is also vital for the most vulnerable groups, including pregnant and breastfeeding mothers and children under five years of age.
“The situation in health clinics cannot be described in words,” says Amelie Chabat, who supervises health programs for the International Committee of the Red Cross in Sudan. “The injured lack medicine, food and water, and the elderly, women and children are deprived of basic treatments such as dialysis or diabetes medications.” “The situation is deteriorating.”
There were numerous reports of looting and vandalism of health facilities, threats and physical violence against staff and patients, and denial of health care services to civilians.
A health system in crisis
The British Medical Journal (BMJ) published a report entitled “Sudan: from a forgotten war to an abandoned healthcare system” in October 2024.
Researchers Amal Al-Amin, Sarah Abdullah, Abda Al-Abadi, Al-Mughira Abdullah, Abda Hakim, Naima Waqi Allah, and John Pastor Ansa said that Sudan is facing the worst humanitarian crisis resulting from the conflict in the world, with the largest internal displacement crisis in the world.
The war destroyed Sudan’s healthcare infrastructure, leading to closures and interruptions in medical services, especially in war-affected areas.
The war is pushing the country into an emerging health crisis, with a move from a double to a quadruple burden of diseases, including infectious and non-communicable diseases, physical injuries and trauma.
The researchers said that, as of February 2024, there are 6.8 million internally displaced people in Sudan, coming from 12 of the country’s 18 states, and 19% of them live in informal settlements, making it the largest internal displacement crisis in the world, surpassing the Syrian crisis. .
In addition, 1.5 million people have been displaced outside the country, and 24.8 million people, nearly half of the country’s population, are in need of humanitarian assistance and protection. Furthermore, Sudan faces acute hunger, with 18 million people suffering from acute food insecurity, including 4 million children under the age of five suffering from malnutrition.
Impact on the health care system
Sudan’s pre-war health system, which includes the WHO health system “components” framework – service delivery, financing, health workforce, medical supplies, health information systems and governance – faced many challenges.
The researchers said that before the war, the health care system was underfunded, characterized by a severe shortage of the health workforce, as well as wide disparities in access, quality, and affordability of care.
95.94% of the population had to pay out of their own pockets for health care services. In addition, the country faced a severe health workforce shortage. In 2019, the density of doctors, nurses, midwives and other health workers was 3.6, 14 and 9.1 per 10,000 people respectively, well below the WHO minimum density of 22.8. From health professionals.
However, the country has been making slow progress towards achieving the Sustainable Development Goals. The current war has further deteriorated the health system and led to the emergence of new challenges, most notably in the provision of services and the health workforce. Health infrastructure has been significantly affected, with the World Health Organization reporting that 70% of public and private healthcare facilities in war-affected states were forced to close by the end of 2023.
Data from the Sudanese Federal Ministry of Health indicate that more than 30% of public hospitals were no longer in service within a year of the start of the war. Khartoum State, the epicenter of the conflict, suffered the greatest impacts on its health system. With the outbreak of armed conflict, thousands of residents and patients from Khartoum State took refuge in Gezira State, located about 200 kilometers southeast of Khartoum, attracted by its relatively available medical infrastructure and proximity. However, by the end of 2023, fighting had spread to Jazira State, endangering not only its residents but also the displaced and sick who fled there in search of safety. Similar to Khartoum State, where 58.5% of public hospitals were forced to close, the expansion of the conflict into Gezira State led to repeated attacks and looting of medical facilities. As a result, many hospitals in Gezira State (56.2% of public hospitals) were closed or forced to reduce their services, exacerbating the conditions of existing displaced people.
Other areas affected by the conflict are located in the southern and western parts of the country, especially in Darfur and Kordofan. In these areas, the operational capabilities of hospitals in some states were affected to varying degrees. Central Darfur State bore the brunt of the impact, with about 40% of its public hospitals forced to close and experiencing severe disruptions to the provision of medical services. Meanwhile, North Darfur, White Nile and North Kordofan faced relatively moderate challenges, with 33%, 26.8% and 16.2% of their public hospitals forced to close, respectively.
In these conflict-affected states, medical facilities are forced to close due to a combination of factors: persistent insecurity, destruction and looting of medical facilities, severe shortages of healthcare workers, and challenges in procuring essential supplies. For example, in war-affected areas where ambulances were looted, residents resorted to using donkey carts and wheelbarrows as makeshift ambulances to transport patients.
The country’s health information systems have been severely compromised due to the deliberate targeting of health communications and information systems, as well as violence against health care workers. These targeted disruptions made data collection and communication extremely difficult, hampering the collection of critical baseline data for the health system.
New challenges
Before the war, the health situation in the country was characterized by a burden of infectious and non-communicable diseases, and the war not only worsened the already deteriorating health situation in Sudan, but also brought new health challenges, such as physical injuries and conflict-related trauma.
This indicates a dangerous shift from a double burden of disease to a quadruple burden – including infectious diseases, non-communicable diseases, physical injuries and trauma – which has exacerbated the health crisis.
The rising number of internally displaced people and the collapse of environmental sanitation have dramatically worsened the burden of infectious diseases. This deteriorating situation is evident in outbreaks of cholera, measles, dengue fever, chikungunya fever and even rising cases of rabies in war-torn areas.
War is expected to increase the problems of individuals living with non-communicable diseases and increase the susceptibility of many others to them. Factors that exacerbate this include displacement and instability, leading to limited access to medical services for screening and follow-up, challenges in obtaining chronic disease medications, treatment interruptions and difficulties in storing medications such as insulin appropriately due to power outages.
Initiatives
Despite ongoing challenges, several initiatives have been essential in supporting healthcare services and mitigating humanitarian crises, researchers say. Community-led efforts, particularly local charity kitchens that provide free meals to individuals trapped in conflict areas, have attracted significant support from the Sudanese diaspora, highlighting the essential role of community engagement in alleviating suffering.
Other initiatives such as the “Call for Reconstruction and Rehabilitation of Hospitals” and the “Call for the Prevention of Malnutrition in Mothers and Children”, launched by the Federal Ministry of Health, have called for support from local, regional and international donors. These initiatives have received significant community participation, and have attracted significant contributions from civil society organizations and professional associations such as the Sudanese American Physicians Association (SAPA) and the Sudanese Doctors Association in Qatar.
Despite national efforts, Sudan’s health care system during the war continues to face major challenges. These challenges include difficulties in implementation and coordination, a fragile health information infrastructure, constraints resulting from limited, unstable and strained resources, and a shortage of health care workers. Moreover, the humanitarian crisis in Sudan is severely underfunded, with donor pledges worryingly falling short of what is needed. Only 5% of the UN aid appeal for Sudan is funded, leaving a staggering $2.56 billion gap.
Researchers say the conflict in Sudan has caused a grim humanitarian and health crisis. Mass displacement, acute hunger, and the psychological and physical effects of war, coupled with the disruption of health service delivery due to hospital closures, all underscore the urgent need for a strong international response.
Despite these dangerous conditions, the resilience and creativity shown by Sudanese health workers and communities is commendable.
The researchers conclude by saying, “The global health community should not allow Sudan to become a ‘forgotten war’ – this scenario must be avoided, starting with restoring its health system.”