When your disease burden is high, resources are low and the migration of your skilled workforce is of constant concern, how is a country to scale-up service initiatives to provide better health care for its citizens? On June 9^th, the Sudanese Medical Association (UK & Ireland) hosted a conference in Galway on the Migration of Sudanese Doctors: Dynamics and Opportunities. The objective of the conference was to highlight the significance and impact of Sudanese doctors’ migration, and several novel ideas were introduced to aid in increasing the capacity of Sudan’s health sector. 

As highlighted by the Federal Minister of Health for Sudan, Mr. Bahar Abugarda, during a presentation on Sudan’s health services, many encouraging improvements have been made in maternal and child health, tuberculosis and malaria infection rates, and government expenditure for health services. However, Mr. Abugarda also addressed a growing double burden of disease with an increase in non-communicable and chronic disease, and Human Resources for Health (HRH) shortages with inequitable distribution across specialties and geographic locations.

The WHO recommends a minimum of 2.5 health workers for every 1000 peoples; in 2008 Sudan had less than half the recommended amount of doctors, nurses and midwives with approximately 1.1/1000¹ individuals. As a way forward, Mr. Abugarda suggested and the creation of unique opportunities by “encourage[ing] and welcome[ing] collaboration between Sudanese and Irish institutions for mutual benefit”.

One such unique opportunity was discussed by Mr. Eric O’Flynn, assistant programme director of the RCSI/COSECSA collaboration programme. The College of Surgeons of East, Central and Southern Africa (COSECSA) and the Royal College of Surgeons in Ireland (RCSI) jointly developed and administered a unique, African-centric, e-learning platform to train surgeons in East, Central and Southern Africa. A severe shortage of qualified surgeons in most African countries coupled with limited training opportunities means that essential medical procedures are often not performed. The collaboration that began in 2007 currently works in 9 countries and is believed to be scalable and cost effective across large distances. Trainees complete online courses and exams, often in one of the 19 provided IT labs, before being certified by COSECSA.

Electronic sources such as the use of mobile phones and tele-medicine for diagnostics assistance in service delivery was also suggested by the working group discussing innovative and sustainable health service delivery, education and research initiatives for Sudan. E-learning offers solutions to challenges posed by lack of trainers and geography in order to increase not only the number of health professionals, but also skill levels. As Mr. O’Flynn stated, “The time of being sceptical about e-learning has passed; now it is the time to put it into action”.

The Sudan Health Library, discussed by co-founded of the SMA and deputy president Dr. Abobakr Shadad, is another innovative idea to improve education training and practice. The online library is accessible to medical students and trainees in Sudan as well as nurses, allied health professionals and researchers. Its objectives are to provide educational resources and to have students in Sudan sharing experiences with peers and instructors from around the world.

Though increasing the absolute number of skilled professionals is pertinent in the efforts to improve Sudan’s health situation, initiatives such as the Sudan Health Library and the Sudan Medical Council (SMA) also recognise the importance of increasing skill levels and capacity of both currently training and trained professionals. For example, the SMA, with Prof. Zein Karrar as President, has succeeded in implementing a national exam for all graduating doctors and regularly holds evaluations and workshops for medical schools.

Changes need to be made in Sudan’s health performance, but there is hope that progress will continue due to innovative efforts such as e-learning, cross-country collaboration and improved in-country standards for teaching. These initiatives must be given support by both the international community and the ministries within Sudan. As stated by Dr. Shadad, “knowledge is the only thing that underlies change”. 

¹ World Health Organization & UNICEF 2012. Building a Future for Women and Children. The 2012 Report.

Brynne Gilmore

Key Correspondent

Email: gilmorb@tcd.ie

This article was written as part of a series of articles written by the Key Correspondent Team (KC Team) covering the Migration of Sudanese Doctors: Dynamics & Opportunities Conference.

For more information on the KC Team go to: www.keycorrespondents.org

On June 9^th, 2012, the Sudanese Medical Association (UK & Ireland), hosted a conference titled Migration of Sudanese Doctors: Dynamics and Opportunities in Galway. The fourth international conference for the SMA, the first in Ireland, brought together health professionals from both Sudan and Ireland, including Sudan’s Federal Minister of Health, Mr. Bahar Idriss Abugarda with the objective to highlight the significance and impact of Sudanese doctors’ migration.

The SMA is an independent, non-governmental academic organisation that formed in 2010 with the objective to upgrade health services in Sudan through collaboration and integration of teams in both Europe and Sudan. Throughout the conference members of the SMA were eager to participate, discuss and share ideas on how to give back to the health sector in Sudan.

During his opening address, Dr. Mahir Hamed, President of the SMA, asked “How can we help junior doctors in Sudan and Ireland?” Annual commitments to work for several months in a Sudanese hospital or to teach in medical schools in Sudan were briefly discussed. Exchange programs or initiatives to bring Sudanese medical students to learn for a period of time in Ireland also gained support from the conference attendees.

Notions of assisting in policy development or medical school curriculum that can draw on the experiences of seasoned Sudanese-Irish professionals were discussed. Also, the idea of researchers using Sudan as a setting to conduct large scale studies was brought up during the working group session. This not only provides researchers with large population samples, but would assist in increasing local capacities by training individuals to be members of research teams.  

However, discussions were not limited to Sudan. The SMA is happy to extend their work to all countries in need, first and foremost South Sudan. As brought up several times throughout the conference, SMA’s lack of political affiliation allows for collaboration with different countries and institutions.

Though discussions were mostly held around what more can the SMA do to support Sudan’s health service, it is important to acknowledge current contributions from its members and other Sudanese-Irish doctors.

A study by Ms. Nuha Ibrahim found that on average doctors that migrated to Ireland support 5 family members back in Sudan. Many migrated doctors, along with providing financial support, contribute to strengthening Sudan’s health sector. Efforts to increase training for medical students and other health staff are already underway as evidenced by the Sudan Health Library, an online database that Dr. Abobakr Shadad states provides educational resources and facilitates collaboration and sharing of experiences between peers and instructors worldwide.

The desire to assist Sudan and its medical professionals doesn’t conform to a yearly allotted travel time-frame or a set amount of weekly hours devoted to programme development. Most Sudanese-Irish doctors, 89% according to Ms. Ibrahim, eventually want to move back to Sudan. Efforts being taken by many doctors currently living in Ireland are ways to stay connected and do as much as possible until they permanently return back to Sudan.

Regardless of where many Sudanese-Irish doctors are located, one thing is for sure: neither Sudan nor Ireland are ever far from their thoughts. As stated by Dr. Shadad, “We are half Irish, half Sudanese. Our children are Irish. That is our country. This is our country”. 

Brynne Gilmore

Key Correspondent

Email: gilmorb@tcd.ie

This article was written as part of a series of articles written by the Key Correspondent Team (KC Team) covering the Migration of Sudanese Doctors: Dynamics & Opportunities Conference 

For more information on the KC Team go to: www.keycorrespondents.org

Dr Abobakr Shadad, lecturer in medicine at NUI Galway, welcomed participants to the Migration of Sudanese Doctors: Dynamics & Opportunities Conference in Galway, Ireland on June 9, 2012 with the Irish saying ‘Tri na cheile a Thogtar na Caisleain’ – We can only build a castle if we work together. This conference was the first Irish conference of the Sudanese Medication Association (of UK and Ireland), and took place over the course of 3 days in both Galway and Dublin. Dr Shadad’s phrase set the tone of the event with many speakers focusing on the theme of collaboration. In particular, Mr. Bahar Idriss Abugarda, Sudan’s Federal Minister of Health (FMOH), echoed these sentiments, stating that he wanted to take the opportunity to “encourage and welcome collaboration and bilateral agreements with Ireland”.

Why Collaborate?

Why is collaboration so essential to tackling doctor migration issues? Is there much value in such partnerships, or is it simply all rhetoric? Currently there’s a large deficit of doctors in Sudan as many emigrate. As Dr Elsheikh Badr (President of the Academy of Health Sciences FMOH Sudan) reported, in 2005 approximately 60% of Sudanese-trained doctors emigrated, and the trend appears to be increasing. Destinations often include the Gulf countries, UK, Ireland, and more recently Libya. Ireland is a country that relies heavily on foreign-trained doctors; Sudanese-trained doctors are increasingly important for the Irish health system.

Collaborative efforts allow Ireland’s government and research institutes to develop a clearer picture of current training needs in Sudan and act on these needs. Overall, partnerships between Sudan and Ireland – through research as well as direct bilateral engagement – aim to help manage doctor migration in the hopes of maximising benefits for both countries.

Methods of Collaboration

Speakers at the conference suggested several ways Ireland and Sudan may collaborate on issues of Sudanese doctor migration.

1.      MOU/bilateral partnership

On June 9 the conference proceedings were temporarily interrupted for the signing of a Memorandum of Understanding (MOU). Sudan’s Federal Minister of Health (FMOH), the Academy of Health Sciences, the School of Nursing and Midwifery at NUI Galway, and the Sudanese Medical Association took part in the signing – a significant step forward in building a bilateral partnership between the two countries.  Such collaboration aims to bring about mutual benefits and protection for professionals against possible exploitation.

2.      Training exchange/twinning

Several presenters focused on the need for training exchange and hospital/medical centre twinning. Ms Helen Burke, an advanced nurse practitioner in diabetes, discussed the pairing of the Diabetes Day Centre, University Hospital Galway. The centre ran a small training exchange programme that brought two diabetes nurses from Sudan to Ireland. She reported a positive overall experience, with the nurses being able to take ideas back to their own centre. With a strengthened skill-specific training curriculum, it may be possible to develop similar, larger-scale programmes in other specialties.  

Mr Eric O’Flynn of the Royal College of Surgeons in Ireland (RCSI) reported on the RCSI collaboration with the College of Surgeons of East, Central, and Southern Africa (COSECSA). A ‘college without walls’, COSECSA is currently in 9 countries. It is a growing and evolving training programme focused on e-learning and distance exam administration. COSECSA is unique because it is Africa-centred. The Sudanese Association of Surgeons has applied to join; Mr O’Flynn stated that he is delighted to be working with Sudanese colleagues and he ‘thinks the future is very bright for this’ and other capacity-building initiatives.

Twinning of hospitals is another means of collaboration that received significant attention at the conference. In February 2012, Ireland joined the ESTHER Alliance – a network of governments working to tackle major diseases and healthcare issues by twinning European hospitals to those in developing countries. At the conference Dr Mohamed Eltom of Portiuncula Hospital, Ireland gave a presentation on ‘Saving Mothers’ Lives’ in which he briefly shared the experience of the Omdurman Maternity Hospital’s collaboration with Irish universities from 2000-2009. He stated that such “collaborations…have proven to be effective in the past” and should similarly be pursued now and in the future.

Dr Ruairi Brugha of RCSI discussed practical training for Irish-trained medical students and doctors in Sudan. He and several colleagues suggested that a programme for a short training in Sudan (perhaps a month or two) would allow doctors trained in Ireland to give back to Sudan and also help them to gain practical training in certain areas, like tropical medicine.

3.      Continuing open dialogues

Several speakers noted the importance of the conference itself as a forum for engaging on challenging topics. Keeping an open dialogue between medical professionals, academics, and policy makers in Sudan and Ireland is crucial for moving forward on key issues. This will help encourage compliance with the World Health Organization’s Global Code of Practice on the International Recruitment of Health Personnel, which is not only about ethical recruitment, but also includes regulations for health system development, health system management, and fair treatment of health workers. Continuing the dialogue on this topic between the two countries gives Ireland the opportunity to identify pressing training needs in Sudan on which Ireland can collaborate. Given the volume of Sudanese doctors in Ireland, it is important to ask what Ireland can be doing to build  capacity that would “help meet the health needs of Sudan and help those doctors who want to return to Sudan”, as stated by Dr Brugha.

It is an exciting time for Sudanese-Irish collaborations around the issues of doctor migration and training. These initiatives must remain truly two-way in nature, as each country has experience and expertise to share with the other. It is only through partnership and working together that they will build castles – or rather, policies and collaborative initiatives that benefit both countries.

Ashton Porter

Key Correspondent

Email: ashton@globalhealth.ie

This article was written as part of a series of articles written by the Key Correspondent Team (KC Team) covering the Migration of Sudanese Doctors: Dynamics & Opportunities Conference.

For more information on the KC Team go to: www.keycorrespondents.org

The Federal Minister of Health (FMOH) for Sudan, Mr. Bahar Abugarda, introduced the Migration of Sudanese Doctors: Dynamics & Opportunities Conference in Galway, Ireland on June 9, 2012, by outlining the achievements, challenges, and a way forward for Sudan’s health system. Like many presenters at the conference, he did not shy away from discussing the difficulties Sudan faces, particularly in terms of Sudanese doctor migration.  However, the FMOH and many other presenters also expressed similar sentiments to Dr Faisal Mihaimeed who stated, “We hope this conference will mark the beginning of a new dawn on the [Ireland-Sudan] relationship” on these issues.

Minister Abugarda discussed the double burden of communicable and non-communicable diseases Sudan’s health system now faces. He noted that coverage of primary healthcare and equitable access remain key challenges. Sudan’s health workforce is concentrated in the large urban centres, creating problems of access in rural areas. There are still weaknesses in the nursing, paramedic, and midwifery sectors in terms of training and capacity. In particular, the Minister stated a need to focus on investing in postgraduate education and training, reproductive health, human resources for health, and health systems management. Spending on healthcare as a percentage of the national budget has yet to reach its targets and needs to increase dramatically. While there has been a slight increase in spending over the past few years, reduction of maternal mortality rates, reduction of child mortality, and improvements in TB and malaria control, the figures are still cause for concern.

Ms. Nuha Ibrahim, researcher at Trinity College Dublin’s Centre for Global Health, presented on the challenges posed by doctor migration from Sudan. She discussed the push and pull factors that lead many doctors and medical students to emigrate from Sudan to Ireland. With this migration comes a loss of capacity, as well as increased coordination and sustainability challenges. A retention strategy for healthcare professionals in Sudan and migration management (a primary focus of this conference) is still a broad area that requires additional attention and work.

Despite these daunting challenges, there are many opportunities for strengthening Sudan’s health system and tackling issues of doctor migration. Minister Abugarda suggested several ways forward for Sudan. Interventions such as scaling up postgrad medical education, scaling up programmes in nursing, midwifery, and paramedical training, focusing on quality assurance, and using and adhering to the World Health Organization’s Global Code of Practice on the International Recruitment of Health Personnel are being considered and implemented. Notably, Minister Abugarda also expressed the need to focus on collaborative efforts with Sudanese doctors abroad and research institutions (including Irish institutions, like the Royal College of Surgeons in Ireland). He suggested a mobilisation of expertise in host countries.

In terms of doctor migration, Sudan is using the National Health Observatory to keep a database on emigrating health workers. Collecting better data will be essential for improving migration and capacity-building policies. There is now a greater political awareness surrounding migration issues, which will help in the coming years as Sudan, Ireland, and many other countries around the world seek to become self-sufficient in supplying their own healthcare workforce. While challenges remain, the Migration of Sudanese Doctors Conference also highlighted progress that has been made in this area and opportunities for the future.

Ashton Porter

Key Correspondent

Email: ashton@globalhealth.ie

This article was written as part of a series of articles written by the Key Correspondent Team (KC Team) covering the Migration of Sudanese Doctors: Dynamics & Opportunities Conference.

For more information on the KC Team go to: www.keycorrespondents.org