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In this blog, Dr Ahmed Khalafalla looks at the war in Sudan and its disastrous consequences for the health system. He outlines his observations about the impacts of war and conflict on patient safety, from shortages of medical equipment to disruptions to vital primary care services. War is the worst thing a person can experience. The history of the civil war in Sudan goes back to the birth of the modern, post-colonial nation. Its sparks erupted in the year 1955 in southern Sudan, with demands for political and human rights in the southern region. Since that date, the country has experienced many internal wars, including the outbreak of this last war on 15 April 2023 in the Sudanese capital, Khartoum. This latest fighting has been fuelled by vertical and horizontal divisions in the Sudanese Armed Forces and paramilitary groups, which have been the tool of this chronic war. As a result of the war, the institutions of the country have gradually abandoned their functional role, and this is seen especially with regard to the provision of healthcare services. During this latest war, many of the health service’s institutions have gone out of service, either due to the lack of equipment and the loss and shortage of healthcare professionals, or because of direct targeting by both sides of the conflict. This targeting is a clear violation of all local and international norms and laws, and means the Sudanese healthcare system faces tragic conditions. It has lost its ability to adapt to bear the burdens of this war throughout the country, and the war has exposed medical teams, first aid teams and emergency committees to many risks related to their own safety. And because patient safety relies on the safety of medical teams, the provision of safe medical services has been disrupted. I have been observing the impact on the health system throughout this latest war, and can see that from the top of the health system management hierarchy, there has been an absence of management. Government institutions lack adequate plans to manage this disaster. Some of the biases and limitations that are associated with power have also had an impact on how the health system has fared. But there is hope. In spite of these challenges, the Sudan Medical Association—represented by its executive committee, its branches in the states, its general assembly and its emergency groups— has displayed leadership and provided a practical alternative that has contributed to the management of healthcare during the conflict. It has been able to organise and direct the healthcare system to adapt to the disaster of the war. According to the latest report of the Sudan Medical Association and its Preliminary Committee, which was issued on 1 June 2023: 66% of hospitals adjacent to war zones are out of service out of (89) basic hospitals in the capital and the states, there are (59) suspended hospitals and (30) hospitals that are fully or partially functioning (some of them provide first aid only. many hospitals are threatened with closure due to the lack of medical staff, medical supplies, water and electricity, According to another report dated 12 June 2023, the number of civilian deaths reached 958, in addition to about 1,000 other deaths in Western Sudan that are not included in the report, and the number of casualties is 4,746. These numbers do not include deaths and injuries among soldiers on both sides of the war. Here are my observations about the impact of war on patient safety: The collapse of leadership, administrative systems and communication management systems has a direct impact on case management, which impacts patient safety. War makes it more difficult for the population to find and access medical and health services. Often, patients cannot be safely and appropriately transported to healthcare facilities. During a war, the quality of healthcare services deteriorates, for example in areas such as infection control and patient falls. Communication between medical teams becomes more difficult. Identifying injured patients and those who have died is very challenging and large numbers remain unidentified. The accumulation of bodies in the roads leads to environmental risks. The collapse of the primary healthcare sector and related services increases patient safety risks for key groups of patients. It becomes harder to follow-up with pregnant women and people with chronic diseases and disabilities. Immunisation services and childhood vaccinations are interrupted and infectious disease and environmental health services cannot fully function, which may lead to emergence of epidemic outbreaks. Lack of availability of medicines, diagnostic and therapeutic medical devices increases the risks to patient safety. Medical staff shortages become much worse. In Sudan there is an acute shortage of medical staff in areas including orthopaedics, general surgery and emergency doctors. Further blogs from Dr Ahmed Khalafalla: Spotlight on Sudan: How can we improve healthcare services during war?

Very little is known about the actual harm that occurs to patients in developing or transitional countries, although the available evidence suggests that they may have an even higher risk of suffering patient harm. Understanding the magnitude of the problem and the underlying factors represents the first step towards improvement. The World Health Organization (WHO) is making a concerted effort, in different parts of the world, to identify the main issues affecting safe care in developing and transitional countries and to use these data to begin to developing and implementing effective solutions. The Eastern Mediterranean/African Adverse Events Study is a large scale study carried out in six Eastern Mediterranean and two African countries, to assess the number and types of incidents that can occur in their hospitals and harm patients. To carry out this study, a collaborative model was established in which 26 hospitals from eight countries, Egypt, Jordan, Kenya, Morocco, South Africa, Sudan, Tunisia and Yemen participated. This document contains the main findings of the Eastern Mediterranean/African Study. It presents some of the risks associated with harm in the participating hospitals, as well as the consequences.

World Pharmacist Day is an initiative by the International Pharmaceutical Federation (FIP) to promote the role that pharmacists play in improving patient safety. In this blog, Roohil Yusuf, Global Pharmacy Advisor at Save the Children, looks at the work of different partners in delivering safe pharmacy services in Afghanistan, Yemen and Sudan.