Primary care clinical practice guidelines in Sudan: A qualitative survey exploring national stakeholders’ perspectives

doi:10.21203/rs.3.rs-5227457/v1

Download PDF

Research Article

Primary care clinical practice guidelines in Sudan: A qualitative survey exploring national stakeholders’ perspectives

https://doi.org/10.21203/rs.3.rs-5227457/v1

This work is licensed under a CC BY 4.0 License

You are reading this latest preprint version

Introduction:

The health system in Sudan faces several challenges, including increasing numbers of patients, shortages of health supplies, and disparities in the distribution of health services. Guidelines implementation improves patients’ outcomes and ensures efficient use of the resources in such a resource-limited country. This paper explored the practice of family medicine at primary health care centers addressing the struggles that impede guideline implementation from the national stakeholders' perspectives.

Methods:

A qualitative facility-based survey conducted in the public referral primary health care centers in Khartoum and Gezira States of Sudan. The study population was composed of practicing family medicine doctors the medical directors in the referral PHC centers. All the focused group discussions and the interviews were audio-recorded. Recordings were transcribed verbatim, and the transcriptions were anonymized. Thematic content analysis was used to analyze the data.

Results:

Local Sudanese guidelines are lacking good publication and regular updating of the recommendations. Most of the surveyed doctors reported reduction of the training programs that are regulated and funded by the ministry of health due to the political and economic situations in Sudan. Barriers to guidelines implementation include limited health insurance coverage, patients’ factors, absence of regular training programs, lack of filing and referral system. Massive deterioration in the family medicine practice at Gezira state was observed due economic and some governmental issues.

Conclusion:

Successful development, adaptation, and implementation of the CPG depends on many factors, including adequate resources, quality assurance, widespread dissemination, appropriate monitoring and auditing for quality improvement. Efforts should be directed to encourage the development of local guidelines through a rigorous approach that involves a multidisciplinary team representing various stakeholders. The government represented by National Health Insurance Fund must expand the health insurance coverage and services. Contribution of the reestablishment of the electronic filing system and the telemedicine consultation in Gezira state and expand the program in Khartoum state and whole Sudan.

Clinical

Guidelines

Implementation

Adherence

Family Medicine

Primary Health Care

Government

Clinical Governance

Stakeholders

Sudan.

Clinical Practice Guidelines (CPGs) are statements that include recommendations intended to optimize patient care. They are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options[1]. As per their definition, CPGs have a great potential to improve the quality of healthcare, and health practice outcomes by minimizing inconsistencies in clinical practice. They are agreed by national health stakeholders not just as critical instruments for providing effective and efficient treatment, but also as increasingly essential in their capacity to transfer the rapid stream of research findings into practical clinical applications [2].

Health System in Sudan:

Federal Ministry of Health (FMOH) in Sudan is responsible for the policymaking, strategic planning, financial and technical support as well as monitoring and evaluation of the overall health system. State ministries of health take responsibility for the planning, provision of secondary and tertiary services, financial and technical support to the localities. Each locality is responsible for primary health care (PHC) service delivery and community services [3].

Remarkable discrepancies between the states, rural and urban areas, and different localities. These discrepancies also manifest in the distribution of health system inputs including human resources, health facilities, and health expenditure. Picture (1-3) shows the buildings of some PHC centers in Khartoum state.

The inefficiency of the health system in Sudan is apparent when comparing health outcomes with health expenditures in Sudan and other developing countries. This is justified by fragmentation in the health system, inefficient financing system, irrational use of medicine and technology, mismanagement of human resources, and lack of quality indicators. Health services coverage is 86% more directed to curative rather than preventive care and secondary and tertiary care rather than primary care[3].

In Sudan, despite many efforts and resources being invested to improve the clinical practice, adherence and implementation of CPGs is still suboptimal due to the financial, professional, and political constraints [4]. Moreover, the practicing doctors face difficulties to customize the international guidelines to the Sudanese context [4, 5]. This highlighted the need to regular development of local protocols that tailed to suit the situation in Sudan[4-6].

CPG development and implementation in clinical practice are complex and challenging processes that can be influenced by various factors at different levels of the healthcare system [7]. This includes organizational, individual levels, and policy-driven strategies including full consideration of the social, cultural, and community contexts to ensure the success and sustainability of CPGs implementation [8]. Utilization of CPGs in healthcare settings necessitates a continuous ongoing process that takes these factors into account and includes all administrators, clinicians, and patients to ensure recommendations are understood, accepted, implemented, and reviewed for continued best practice adoption [9].

Stakeholders' involvement is proven to be a crucial component in the development and implementation of CPGs, through the formulation of clinical questions, reviewing the final documents, and suggesting strategies to identify, specify, and prioritize implementation strategies[10]. They contribute essential insights into implementation variables, such as detailed knowledge of processes, organizational architecture, culture, available resources, and other difficulties that may prevent effective implementation. engaging stakeholders in the identification, operationalization, and selection of implementation strategies increases the likelihood that such strategies will be adopted and sustained [11].

Despite the growing interest in and demand for research that engages stakeholders in the CPGs, still, the role of stakeholders, particularly service providers in acceptance and involvement in development and implementation efforts, has received relatively little attention regionally and particularly in Sudan [12]. Thus, this paper aims to explore the main attributes affecting CPGs implementation and adherence in the Sudanese health system from the perspective of the key stakeholders operating at the national level.

The paper was part of a qualitative facility-based survey conducted in the public referral primary health care centers in Khartoum and Gezira States in Sudan during the period from April to December 2021. The study population was composed of practicing family medicine doctors and the medical directors in the referral PHC centers. A total of 101 primary health care centers were surveyed (77 centers in Khartoum state and 24 in Gezira state). Focused group discussion and a semi-structured in-depth interview were done for the family doctors. The interviews aimed to extract in-depth information about barriers and facilitators of adherence to clinical practice guidelines. Eight focused group discussions were done with groups of family medicine doctors (4 form Khartoum state and 4 from Gezira state). Four in-depth interviews were done with the primary health care medical directors in Khartoum and Gezira states. All the focused group discussions and the interviews were audio-recorded. Notes were taken during and after each interview to complement the information. Recordings were transcribed verbatim, and the transcriptions were anonymized. Interviews were 15 minutes long on average. Data was collected by the principal investigator and a research assistant who was trained on qualitative data collections and was supervised by research fellows. All data were collected in a one month. Qualitative data were recorded, transcribed, coded then analyzed using content analysis approach. Depersonalization of qualitative findings was carried out to visualize differences in views and responses.

Ethical clearance and approval for conducting this research was obtained from Federal Ministry of health (FMOH) authorized ethical committee. Permission was obtained from the directors of the primary health centers. Written consent was taken from all participants with assurance with confidentiality and all rights. The purpose of the study was addressed briefly. Confidentiality and privacy have been maintained during data collection, analysis and reporting.

Focused group discussion and in-depth interview results:

Guidelines in Sudan:

Concerning the local guidelines many doctors complained of absence of local Sudanese guidelines that cover most of the common medical circumstances. Furthermore, the available local Sudanese guidelines are lacking good publication and regular updating of the recommendations. Doctors recommended good publication of the Sudanese guidelines through the social media and by posters in the PHC centers.

“The international guidelines must be modified to suit the local settings of the Sudanese or developing local treatment protocols that based on studies done in Sudan. Some of the international guidelines are difficult to be implemented in Sudan due to many factors which include cost and or unavailability of the drugs and unavailability of the investigations in the distant and rural areas”.

“The local Sudanese guidelines recommendations are sometimes differed from the international guidelines… and these differences affect the trust of the practicing doctors and the patients as well. This because of absence of evidence-based studies and good publication. But the condition doesn’t apply to other international guidelines, for example malaria treatment protocol which is always funded and published by the WHO is always updated and well trusted”.

“Generally, there is no obvious regular updating of the local guidelines, and we just heard about the local Sudanese hypertension guidelines, but we have ever seen it. The only guideline that is regularly updated is the malaria protocol because it funded by the WHO”.

Training programs to the practicing family medicine doctors:

Most of the surveyed doctors reported the presence of training programs and workshops that are regulated and funded by the ministry of health (MOH) especially for family medicine doctors. Recently, the training programs have decreased or even stopped due to the political situation in Sudan. Also the COVID19 pandemic played an important role in impending training programs. Despite the presence of funded training programs for the practicing family medicine doctors, frequency of the training programs is not sufficient to cover all the important topics. Additionally, the chance to attend the training programs is sometimes limited and not equally distributed between Khartoum and Gezira states.

“The workshops occur, and doctors require more training programs to remind them regularly. The training programs tend to cover only chronic diseases and not occur regularly.

Barriers to guidelines implementation:

Most of the interviewed family medicine doctors (95%) in Khartoum and Gezira states identified limited health insurance coverage and patients’ low economic status as main barriers to guidelines implementation. Additionally, high load of the patients, absence of regular training programs, lack of filing and referral system are identified as barriers to guideline implementation, as displayed in Figure (1). Clinical audit is also required to evaluate and improve clinical practice.

“There are many factors that impede guideline implementation, which include health insurance limited services and patients’ low economic status and other patient factors…. Also the economic and the political situations in Sudan play an important role…, we hope if all these factors can be corrected”.

“The barriers consist of three levels, system, patients and doctors’ barriers. Regarding the system barriers cost and availability of the drug and the health insurance coverage… and the importance of presence of instructions to be followed. Regarding the doctors’ barriers, the importance of training, increasing knowledge and encouraging doctors’ communication. Regarding the patients’ barriers, presence of language communication barrier….”.

Health insurance in Sudan:

The governmental health insurance in Sudan covers only the routine investigations and some of the cheap drugs. This limited coverage impedes guidelines implementation, and consequently many doctors tend to waive some investigations and to prescribe second or even third line treatment only because it’s the treatment that covered by the health insurance.

“The coverage of the health insurance is very difficult and therefore obstructs guideline implementation, and due to the economic situations, we can’t write certain treatment or recommended investigation. Therefore, doctors tend to follow certain ways due to the above-mentioned factors. And to emphasize, sometimes we tend to prescribe the second line treatment”.

In Gezira state, family medicine registrars reported that the policy of the governmental health insurance is to consider the family medicine registrars as medical officers and consequently they are allowed only to prescribe certain medications. Family medicine registrars are permitted to use the (black form) which is the form that designed to be used by the medical officer. This situation only in Gezira state, while in Khartoum state the family medicine registrars are allowed to use the (red form) which is the form that used by the specialists and permit them to order all the investigations and to prescribe all the drugs at the PHC level.

Deterioration of family medicine practice in Gezira state:

Most of the practicing family medicine registrars in Gezira state reported deterioration in the family medicine practice. The family medicine program was supported and funded by many organizations. They used to give any practicing family medicine doctor in Gezira state personal computer and internet connection. They used to implement the electronic filing system and telemedicine. The family medicine doctors were in contact with specialists and consultants of all specialties, and they do online consultations when they need. The online consultation allows the consultant to see the patient and the family medicine doctor through the camera. Furthermore, home care program was activated for geriatrics and disabled patients. Additionally, a special server (icloud) was used to collect the data. Doctors consider the government, and the concerned directors, are responsible of this deterioration. In addition, family medicine doctors in Gezira state think there is a political issue behind this deterioration.

The primary health care centers are not well constructed and don’t contain all required departments and enough staff compared to Khartoum state. Additionally, some of the basic and routine investigations are not available in all PHC centers, doctors tend to refer the patients to do their investigations. The doctors in Gezira state requested improvement of the situation and building in the PHC centers especially in the rural and distant areas, in which they are lacking in the essential departments.

“The coverage of the health insurance is very difficult and therefore obstructs guideline implementation…, and due to the economic situations, we can’t write certain treatment or recommended investigation. Therefore, doctors tend to follow certain ways due to the above-mentioned factors. And to emphasize, sometimes we tend to prescribe the second line treatment”.

“Family medicine registrars are not allowed to use the red form and considered as a medical… and this is not occurring in Khartoum. This makes us to refer our patients to the specialist just to prescribe medication like ‘Amoclan’, and this reflects badly the patients as well … and we hope if the situation can be changed to the better”.

Results of the study reported good adherence and implementation of the guidelines. Local Sudanese guidelines need to be accessible and regularly updated. These results are similar to Abdelgadir et al. as they reported high implementation rate to the guidelines and lack of good publication to the Sudanese guidelines [4, 5].

Implementation of guidelines in Sudan is limited mainly by restricted health insurance coverage and patients’ low economic status. These two factors force the practicing doctors to waive the guidelines recommendation and to manage their patients according to the available medications and investigations. Other factors include few working doctors, lack of training programs and filing system. The location of the referral PHC centers, availability of the essential investigations and the coverage of the health insurance are considered as essential factors in improving the quality of care. Abdelgadir et al. focused the light on the limited coverage of the health insurance services in Sudan [4]. Availability of the heath cervices, patents factors and the other economic situations affects doctors’ plans and adherence to the guidelines [4, 5].

The study reported reduction in the regulated training programs due to the political issues in Sudan. The qualitative results also focused on the National Health Insurance Fund (NHIF), which is limited especially in Al Gezira state. Furthermore, results highlighted the poor construction of many of the primary health care centers. Abdelgadir et al and Nurelhuda et al. addressed the same issue. The economic situation in Sudan was responsible in these deteriorations and inequality [4, 13]. The rural areas additionally suffer from limited number of qualified doctors and enough staff. Encouragement of junior doctors and residents to work in the remote areas was one of the global policy recommendations [3,14].

Practice in Sudan impedes guidelines implementation due to limited financial and medical resources along with the poor construction and absence of the basic departments and enough staff. Economic deterioration in Sudan resulted in decreasing the quality of health system supply. This affected the reconstruction fund in the MOH. Furthermore, doctors tend to travel outside Sudan searching for better salaries and lifestyles. Many studies addressed the barriers to guidelines implementation [15, 16].

Family medicine practice had deteriorated in Gezira state. The economic and political situations play an important role in this deterioration, beside the governmental plan and the health insurance strategies. Furthermore, some policies of the NHIF and the MOH in Gezira state hamper family medicine doctors’ practice by dealing with them as medical officers. The Sudan national health policy report addressed the same issue as they reported inequality of the health system fund and supply. They addressed the problem of inequality which includes a clear difference in health system between the states in Sudan and even between the rural and urban areas and the localities [3].

The primary health care in Sudan, since its establishment faced many struggles due to the political issues and economic situations. The health insurance limited coverage, patients’ factors, services unavailability and inaccessibility are considered as essential factors affecting guidelines implementation. Practicing doctors face many problems that impede them from implementation of the CPGs. Service cost, unavailability of the service, lack of health insurance coverage and patents wish are the common barriers to CPGs implementation. The economic situation in Sudan resulted in deterioration in the health care system in General. In Gezira state, noticeable deterioration in the family medicine practice was noted. Telemedicine in Sudan was started in Gezira state among the practicing family medicine doctors at the PHC levels. This deterioration resulted in the stopping of the telemedicine health services. Furthermore, some of the governmental rules that have a notable difference between the health system regulations between the states in Sudan, the practice of family medicine was differ in Khartoum and Gezira states. The concentration to improve the health system in the capital of Sudan/ Khartoum, along with the deterioration of the economic situation in Sudan were the main reason of the declined of the health system in Gezira state.

Recommendations:

The government represented by National Health Insurance Fund (NHIF) must expand the health insurance coverage and services. Ministry of health in Sudan with collaboration with the Sudan Medical Specialization Board (SMSB) must expand the regulated Continuing Medical Education (CME) and Continuing Professional Development (CDP) and other training programs for family medicine doctors to be applied in all states of Sudan. Furthermore, insurance of equal chances of the training programs and consideration of the geographical variations. Encouragement of regular auditing in the PHC centers, regular evaluation and follow up of the practicing family medicine doctors by the MOH. State ministry of health (SMOH) must encourage and support the concerned societies and departments to issue and regularly update the national Sudanese guidelines. Contribution of the reestablishment of the electronic filing system and the telemedicine consultation in Gezira state and expand the program in Khartoum state and whole Sudan. The NHIF and SMOH need to reevaluate the policies that prevents the family medicine registrars in Gezira state to use the health insurance red form and to have permitted them to practice according to their job description. Successful development, adaptation, and implementation of the CPGs depends on many factors, including adequate resources; quality assurance; widespread dissemination; implementation in health systems and by healthcare providers; and appropriate monitoring and feedback for quality improvement. Efforts should be directed to encourage the development of local guidelines through a rigorous approach that involves a multidisciplinary team representing various stakeholders including and working with explicit harmony. These approaches must be accompanied by the development of tailored interventions to implement the guidelines. A comprehensive strategy to disseminate the guidelines via various channels, both written and personal, is crucial, scientific journals, local networks of peers, and colleagues trained to explain the guidelines should be part of such a strategy. Policymakers should establish a national system to collect, disseminate, and implement guidelines, strengthen the management of conflict of interest, and provide quality assurance and control.

Strengths and limitations of the study:

Our study had several strengths such as engaging a competent research team with prior training in qualitative interviewing; sound knowledge of the CPGs as well as research skills, and negotiating with experts; Moreover, engagement of members from different disciplines including clinicians, academics, public health, and quality consultants from SMOH, FOMH who figured out any gaps in the process, and had valued inputs. The study investigated healthcare providers and authorities without involving patients as service users and important stakeholders who are considered active rather than passive change agents, recognizing them as experts with valued contributions in well-informed healthcare decisions.

AICs: Agency for Italian Cooperation, CPGs: Clinical Practice Guidelines, CME: Continuing Medical Education (CME), Continuing Professional Development (CDP), FMOH: Federal Ministry of Health, FMOF: Federal Ministry of Finance, PHC: Primary Health Care, MD: Medical Doctorate, MOH: Ministry of Health, NHIF: National Health Insurance Fund, SMOH: State Ministry of Health, SMSB: Sudan Medical Specialization Board.

Ethical approval and consent to participate:

Ethical clearance and approval for conducting this research were obtained from the Federal Ministry of Health (FMOH) authorized ethical committee. Permission was obtained from the directors of the primary health centers. Written informed consent was taken from all participants with assurance of confidentiality and all rights. The purpose of the study was addressed briefly. Confidentiality and privacy have been maintained during data collection, analysis, and reporting.

Consent to publish:

Not applicable.

Availability of data and material:

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Competing interests:

The authors declared that they had no competing interests.

Funding

We declare that this study was fully funded by the Agency for Italian Cooperation (AICS) and was technically and operationally supervised by the Sudan National Public Health Institute (PHI).

Authors’ contributions:

Hiba Salah: Designed and implemented the study protocol, study tool, participated in the data collection, conducted the data analysis, participated in writing the final research draft, and the manuscript.

Sahar Bajouri: Reviewed and edited the study protocol, study tool, supervised the field implementation of the research and all data management processes, participated in writing the final research draft, and the manuscript.

Hind Salah: Proofread read and edited the final manuscript.

All authors approved the final version of the manuscript before submission.

Acknowledgments:

Thanks and appreciation to Dr. Osama AlShafee, Dr. Muhammed ELhassein, and Dr. Salwa Mudatir Ismael for their help and guidance during the study. Special thanks to Dr. Abdelkhalig Ibrahim, Dr. Sahar Faisal Mohamed Makawi, Dr. Ghedwa Awad Said Ahmed, Dr. Sumia Kabbar, Dr. Hala Satti and Dr. Mohamed Elfadil for their efforts and support. Appreciation and thanks to Dr. Salah Abdelradir Abdelmagid for his guidance and support.

Guerra-Farfan, E., Garcia-Sanchez, Y., Jornet-Gibert, M., Nuñez, J.H., Balaguer-Castro, M. and Madden, K., 2023. Clinical practice guidelines: The good, the bad, and the ugly. Injury, 54, pp.S26-S29.
Milojevic, M., Nikolic, A., Bakaeen, F.G. and Myers, P.O., 2024. Clinical practice guidelines: ensuring quality through international collaboration. European Journal of Cardio-Thoracic Surgery, 66(1).
Sudan’s National Health Policy 2017-2030, World health organization country planning database, accessed at 5.10.2024. Avilable at: https://extranet.who.int/countryplanningcycles/sites/default/files/public_file_rep/SDN_Sudan_National-Health%20Policy_2017-2030.pdf.
Abdelgadir, H.S., Bajouri, S. and Abdelgadir, H.S., 2024. Implementation of the clinical practice guidelines among family medicine doctors at primary health care facilities in Khartoum and Gezira states of Sudan. BMC Primary Care, 25(1), p.277.
Abdelgadir HS, Elfadul MM, Hamid NH, Noma M. Adherence of doctors to hypertension clinical guidelines in academy charity teaching hospital, Khartoum, Sudan. BMC health services research. 2019 Dec;19:1-6.
Abdelgadir HS, Magboul M, Salih M, Ahmed M, Abdelgadir HS, Ahmed MA. Adherence of Doctors to Diabetes Clinical Guidelines in Sudan. Journal of Family Medicine and Health Care. 2024, vol. 10, No. 3, pp 60-66. DOI: https://doi.org/10.11648/j.jfmhc.20241003.13.
Peters, S., Bussières, A., Depreitere, B., Vanholle, S., Cristens, J., Vermandere, M. and Thomas, A., 2020. Facilitating guideline implementation in primary health care practices. Journal of Primary Care & Community Health, 11, p.2150132720916263.
Wang, T., Tan, J.Y.B., Liu, X.L. and Zhao, I., 2023. Barriers and enablers to implementing clinical practice guidelines in primary care: an overview of systematic reviews. BMJ open, 13(1), p.e062158.
Beauchemin, M., Cohn, E. and Shelton, R.C., 2019. Implementation of clinical practice guidelines in the health care setting: a concept analysis. Advances in nursing science, 42(4), pp.307-324.
Bennett, W.L., Robbins, C.W., Bayliss, E.A., Wilson, R., Tabano, H., Mularski, R.A., Chan, W.V., Puhan, M., Yu, T., Leff, B. and Li, T., 2017. Engaging stakeholders to inform clinical practice guidelines that address multiple chronic conditions. Journal of general internal medicine, 32, pp.883-890.
Proctor, E.K., Powell, B.J. and McMillen, J.C., 2013. Implementation strategies: recommendations for specifying and reporting. Implementation science, 8, pp.1-11.
Kredo, T., Abrams, A., Young, T., Louw, Q., Volmink, J. and Daniels, K., 2017. Primary care clinical practice guidelines in South Africa: a qualitative study exploring perspectives of national stakeholders. BMC health services research, 17, pp.1-12.
Nurelhuda N, Bashir A, ElKogali S, Mustafa M, Kruk M, Aziz MA. Encouraging junior doctors to work in rural Sudan: a discrete choice experiment. Special issue on scaling up health workforce in the Eastern Mediterranean Region. 2018;24(9-2018).
Organization WH. Increasing access to health workers in remote and rural areas through improved retention: global policy recommendations: World Health Organization; 2010.
Qumseya B, Goddard A, Qumseya A, Estores D, Draganov PV, Forsmark C: Barriers to clinical practice guideline implementation among physicians: a physician survey. International Journal of General Medicine 2021, 14:7591.
Birrenbach T, Kraehenmann S, Perrig M, Berendonk C, Huwendiek S: Physicians’ attitudes toward, use of, and perceived barriers to clinical guidelines: a survey among Swiss physicians. Advances in medical education and practice 2016, 7:673.

No competing interests reported.

Download PDF

Editorial decision: Revision requested
14 Oct, 2024
Editor assigned by journal
11 Oct, 2024
Submission checks completed at journal
11 Oct, 2024
First submitted to journal
08 Oct, 2024

You are reading this latest preprint version

Primary care clinical practice guidelines in Sudan: A qualitative survey exploring national stakeholders’ perspectives

Status:

Version 1

Abstract

Figures

Introduction

Methods

Results

Discussion

Conclusions

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1