A multi-state cross-sectional assessment of essential medicine availability in Sudan during armed conflict

Abstract

The armed conflict that erupted in Sudan in April 2023 has severely disrupted the country’s healthcare system, affecting hospitals, community pharmacies, and essential health services, including pharmaceutical supply chains. This study aimed to evaluate the influence of the persistent armed conflict in Sudan on the accessibility of essential medications in community pharmacies within designated states. It aims to pinpoint critical factors influencing medicine supply, assess availability across regions, and investigate the strategies employed by pharmacists to ensure access to essential medications. This study examines geographic variation, pharmacy type, and barriers to medicine access to enhance humanitarian planning, national policy responses, and pharmaceutical resilience strategies in prolonged crisis contexts. A cross-sectional survey was conducted between December 2024 and May 2025 using the WHO/HAI methodology. The WHO/HAI methodology is a standardized, international survey method developed by the World Health Organization (WHO) and Health Action International (HAI) to measure the price, availability, and affordability of essential medicines in both public and private sectors. Data were collected from 118 public and private community pharmacies across Aljazeera, Northern, White Nile, and Red Sea states. Availability of 50 essential medicines was recorded through a structured questionnaire. Descriptive statistics, t-tests, and ANOVA were used to analyze differences by pharmacy type and location. Overall, 95.8% of pharmacies reported disrupted access to medicines, and 98.3% reported significant price increases. Chronic disease medications such as insulin (11.0%), diazepam (15.3%), and captopril (26.3%) were among the most unavailable. Public pharmacies showed significantly higher average availability than private ones (p = .04), while Northern State reported higher availability than Aljazeera and Red Sea states (p < .001). Essential medicine availability in Sudan has been critically undermined by the conflict, with chronic disease treatments disproportionately affected. These findings highlight the urgent need for secure pharmaceutical supply corridors, support for local production, and coordinated humanitarian efforts to restore medicine access in conflict-affected areas.

Introduction

Access to essential medicines is a fundamental human right and a key part of health systems that work. However, in areas affected by conflict and instability, this access is severely limited, resulting in dire implications for public health and human survival. Over two billion people around the world still can’t get the medicines they need, and the burden falls most heavily on people in low- and middle-income countries^1–6. Armed conflict is a particularly devastating disruptor of pharmaceutical systems, affecting everything from supply chains and local manufacturing to healthcare delivery and affordability^7–10. Sudan’s health system has had structural problems for a long time, such as relying on imported medicines, weak regulation, and not making enough medicines locally^11,12. Since the start of the armed conflict in April 2023, these pre-existing weaknesses have been severely exposed. More than 8 million people have been forced to leave their homes, more than two-thirds of healthcare facilities have closed, and health infrastructure has been widely looted or destroyed^13–16. Recent studies show that chronic disease medications, such as insulin and antihypertensives, are becoming less available. At the same time, emergency and acute care drugs are becoming harder to find or too expensive^14,15,17. The armed conflict has stopped local production, leaving less than 30% of manufacturers still in business, and made humanitarian supply corridors less reliable^{14,15,17–22}. Pharmacies, especially public ones, have closed because of safety concerns, lack of supplies, and workers being displaced. The effects are similar to what has been seen in other conflict zones, like Syria, Yemen, Ukraine, and Gaza, where medicine shortages during long-lasting crises caused huge increases in preventable death and illness^1,2,8,23,24. Although numerous global reports and qualitative studies have investigated the health impacts of armed conflict in Sudan, empirical data regarding community-level medicine availability remain scarce. This study aimed to address the deficiency by evaluating the accessibility of essential medicines in community pharmacies—both public and private—across four distinct states (Aljazeera, White Nile, Northern and Red Sea) in Sudan amid the ongoing conflict. Red Sea and Northern states, experienced intermittent insecurity rather than continuous hostilities.

This study examines geographic variation, pharmacy type, and barriers to medicine access to enhance humanitarian planning, national policy responses, and pharmaceutical resilience strategies in prolonged crisis contexts.

Methodology

Study design, setting and the study sites

This was an observational cross-sectional study conducted to assess the availability of essential medicines in community pharmacies across four Sudanese states: Aljazeera, Northern, White Nile, and Red Sea. The information collected in this study was primarily descriptive and qualitative in nature. No formal scaling, scoring, or weighting system was applied during data collection or analysis. The study followed a modified World Health Organization/Health Action International (WHO/HAI) methodology (2008), with adaptations to the sampling framework due to contextual and logistical constraints²⁵. These four states were purposively selected to capture variation in geography, conflict exposure, and socio-economic conditions. The target population included public and private community pharmacies operating in these states during the conflict period. Both types of pharmacies were included to provide a comprehensive view of medicine availability in the country’s mixed public–private pharmaceutical landscape.

Sampling strategy and sample size

A stratified purposive sampling approach was employed to ensure representation from both public and private pharmacies across the four states. Due to conflict-related logistical and safety challenges, traditional probabilistic sampling and formal sample size calculation could not be implemented. Instead, pharmacies were selected based on accessibility, operational status and consent to participate in alignment with WHO/HAI’s minimum sampling guidance for facility-based surveys in fragile settings. A total of 118 pharmacies were successfully surveyed, distributed as follows: Aljazeera (n = 59), Northern (n = 28), Red Sea (n = 27), and White Nile (n = 4). Among these, 102 (86.4%) were private and 16 (13.6%) were public. The predominance of private pharmacies in the sample reflects the broader pharmaceutical infrastructure in Sudan, where private sector outlets substantially outnumber public facilities and frequently serve as the primary source of medicines, particularly in peri-urban and rural settings.

Data collection tool and procedure

Data were collected using a structured, self-administered questionnaire developed based on WHO/HAI guidelines. The tool consisted of two sections:

1. Pharmacy and operational characteristics – including location, ownership (public or private), status during the conflict, and supply challenges, pharmacy characteristics included location, ownership (public/private), operational status during the conflict (open, temporarily closed, permanently closed), and supply challenges.

2. Essential medicine availability checklist – the checklist comprised 50 essential medicines selected by the study team based on the Sudanese National Essential Medicines List and their frequent use in routine clinical practice, ensuring a practical and representative assessment of medicine availability across pharmacies.

The questionnaire was pre-tested in a pilot group of pharmacies to ensure clarity and contextual relevance. Data collection was conducted between December 2024 and May 2025. Pharmacists were asked to complete the questionnaire either in person or, when security risks prevented field visits, via phone interviews. Participation was voluntary and based on informed verbal consent.

Data management and analysis

All pharmacies were entered into Microsoft Excel and analyzed using IBM SPSS version 26. Descriptive statistics (frequencies, percentages) were used to summarize medicine availability and reported challenges. Chi-square tests were used to assess associations between pharmacy type and medicine availability. An independent t-test and one-way ANOVA were applied to compare mean availability scores across pharmacy types and states, with p-values < 0.05 considered statistically significant. Cohen’s d was calculated to assess the effect size of observed differences.

Results

A total of 118 pharmacies were surveyed across four states. 86.4% (n = 102) were private and 13.6% (n = 16) were public. Aljazeera State had the highest number, with 56 private and 3 public pharmacies, totaling 59. The Northern State followed with 28 pharmacies (19 private and 9 public), while the Red Sea State had 27 (25 private and 2 public). White Nile State had the fewest, with 4 pharmacies equally divided between private and public [Table 1].

Table 1.

Distribution of pharmacies by type and state-Sudan (n = 118).

Location	Type of pharmacy N = 1181
	Private pharmacy	Public pharmacy	Total
Aljazeera state	56	3	59	50.0%
Northern state	19	9	28	23.7%
White Nile state	2	2	4	3.4%
Red Sea State	25	2	27	22.9%
Total	102	16	118	100%

¹n (%).

Medicine supply before and after the start of the conflict

The majority of medicine supplies originated from Khartoum State, accounting for 39.0% (n = 46) of pharmacies, followed by 27.1% (n = 32) who sourced medicines from both Khartoum and their local state. However, after the conflict, this reliance on Khartoum significantly dropped to just 4.2% (n = 5), likely due to the ongoing conflict. Previously, many healthcare providers sourced medicines from both Khartoum and their local state, but disruptions in supply chains, transportation challenges, and safety concerns have increasingly forced them to rely primarily on local or regional sources. In contrast, local sourcing increased markedly from 18.6% (n = 22) before the conflict to 37.3% (n = 44) after, and sourcing from other states (excluding Khartoum) rose from 8.5% (n = 10) to 35.6% (n = 42). Additionally, sourcing from both local and non-Khartoum states increased from 0.8% (n = 1) to 16.9% (n = 20), while medicines obtained from outside Sudan, previously 0.0%, rose slightly to 4.2% (n = 5) (Fig. 1).

Fig. 1.

Changes in sources of medicine supply during the conflict-Sudan (n = 118).

Effect of conflict in accessibility and price of medicines

The majority of pharmacies reported being affected by the conflict in various ways. Access to medicines was disrupted for 95.8% (n = 113) of pharmacies, with only 4.2% (n = 5) remaining unaffected. Similarly, 98.3% (n = 116) experienced an increase in medicine prices, while just 1.7% (n = 2) reported no impact. Additionally, 95.8% (n = 113) of pharmacies faced difficulties in obtaining medicines. (Table 2)

Table 2.

Disruptions in medicine availability and pricing among community pharmacies.

Impact of the conflict on pharmacies	Number of pharmacies (n/%)
Disrupted access to medicines	113 (95.8)
No disruption in access	5 (4.2)
Increased medicine prices	116 (98.3)
No increase in medicine prices	2 (1.7)
Difficulties in obtaining medicines	113 (95.8)

The most commonly reported difficulty across all states was an increase in price 75.4% (n = 89), followed by delivery problems 69.5% (n = 82) and reduction in local manufacturing across Sudan 66.9% (n = 79). Importation problems were noted by 49.2% (n = 58) of pharmacies, while communication issues with health care authorities and companies were reported by 42.4% (n = 50) (Table 3).

Table 3.

Difficulties in getting medicines during the conflict (Frequency) (n = 108).

Challenges	Aljazera	Northen	White Nile	Red Sea	Total (n)
Increase in price	45	25	2	17	89
Delivery problems	40	22	4	16	82
Importing problems	24	19	1	14	58
Reduction in local manufacturing	42	19	3	15	79
Health care communication barriers	21	17	0	12	50
Other challenges	4	8	1	3	16
Total frequency of challenges reported	176	110	11	77	374
Total premises surveyed out	54	27	4	23	108

A total of 374 challenges were reported from 108 surveyed pharmacies across the four study locations. The most frequently reported challenge was increased medicine prices (n = 89), followed by delivery problems (n = 82) and reduction in local pharmaceutical manufacturing (n = 79). Importation-related problems were also commonly reported (n = 58).

Distribution of reported difficulties across all states (frequency)

During the conflict, the most commonly available drugs were Amoxicillin with Clavulanic acid 875 + 125 mg 93.2% (n = 110), followed closely by Paracetamol 500 mg 92.4% (n = 109). In contrast, Neutral soluble insulin and Diazepam were identified as the most deficient drugs during this period. These findings are detailed in [Table 4] and illustrated in (Fig. 2), where part (A) displays the most available drugs and part (B) shows the most deficient ones.

Table 4.

Frequency and proportion of drug presence and shortages (n = 118).

Critical medications	N = 1181
	Available		Shortage
1. Amoxicillin + Calvulanic Acid 875 + 125 mg	110	93.2%	8	6.8%
2. Paracetamol 500 mg	109	92.4%	9	7.6%
3. Omprazole 20 mg	108	91.5%	10	8.5%
4. Salbutamol Inhaler	107	90.7%	11	9.3%
5. Metronidazolle 500 mg	107	90.7%	11	9.3%
6. Artemether +Lumefantrine	106	89.8%	12	10.2%
7. Adult cough preparation	105	89.0%	13	11.0%
8. Diclofenac 50 mg	103	87.3%	15	12.7%
9. Fefol	102	86.4%	16	13.6%
10. Metformin HCL 500 mg	101	85.6%	17	14.4%
11. Amoxicillin + Calvulanic Acid 250 + 125 mg	98	83.1%	20	16.9%
12. Iboprofen 400 mg	97	82.2%	21	17.8%
13. Ceftrixone 5 mg	94	79.7%	24	20.3%
14. Amoxicillin 500 mg	90	76.3%	28	23.7%
15. ORS	88	74.6%	30	25.4%
16. Atorvastatin 20 mg	86	72.9%	32	27.1%
17. Cefixime 400 mg	85	72.0%	33	28.0%
18. Amlodipine 5 mg	83	70.3%	35	29.7%
19. C0-trimoxazole	82	69.5%	36	30.5%
20. Hyoscine-N-Butylbromide 10 mg	82	69.5%	36	30.5%
21. Ciprofloxacin 500 mg	76	64.4%	42	35.6%
22. Paracetamol Syrup	75	63.6%	43	36.4%
23. Metronidazol 200 mg	74	62.7%	44	37.3%
24. Amoxicillin suspension	73	61.9%	45	38.1%
25. Artesunate 120 mg	70	59.3%	48	40.7%
26. Salbutamol Syrup	67	56.8%	51	43.2%
27. Dexamethasone injection	64	54.2%	54	45.8%
28. Carbamazepine 200 mg	63	53.4%	55	46.6%
29. Lisinopril 10 mg	61	51.7%	57	48.3%
30. Nifedipine Retard 20 mg	60	50.8%	58	49.2%
31. Diclofenac 25 mg	57	48.3%	61	51.7%
32. Gliclazide 80 mg	56	47.5%	62	52.5%
33. Furosemide 40 mg	55	46.6%	63	53.4%
34. Chloramphenicol eye drops	53	44.9%	65	55.1%
35. Norethisterone 5 mg	53	44.9%	65	55.1%
36. Fluoxetine 20 mg	52	44.1%	66	55.9%
37. Artesunate 60 mg	48	40.7%	70	59.3%
38. Amitriptyline 25 mg	43	36.4%	75	63.6%
39. Glibenclamide 5 mg	40	33.9%	78	66.1%
40. Albendazole 200 mg	40	33.9%	78	66.1%
41. Azithromycin Sus	41	34.7%	77	65.3%
42. Carbimazole 5 mg	40	33.9%	78	66.1%
43. Artemether injection	39	33.1%	79	66.9%
44. Atenolol 50 mg	31	26.3%	87	73.7%
45. Captopril 25 mg	31	26.3%	87	73.7%
46. Beclomethasone inhaler	28	23.7%	90	76.3%
47. Simvastatin 20 mg	24	20.3%	94	79.7%
48. Diazepam 50 mg	18	15.3%	100	84.7%
49. Insulin, Neutral soluble	13	11.0%	105	89.0%

¹n (%).

Fig. 2.

Medications shortages and availability among pharmacies.

Independent t-test and ANOVA results indicated statistically significant mean differences based on pharmacy type and state, leading to the rejection of the null hypothesis. Cohen’s d statistic for pharmacy type was 0.547, indicating a medium effect size, while for differences among states, Cohen’s d was 0.322, representing a small to medium effect size. Regarding pharmacy type, public pharmacies had an average availability of four critical medications more than private pharmacies at p = .04. Regarding locations, post-hoc comparisons using the Tukey HSD test indicated that the Northern State had a significantly higher mean number of available medications compared to both Aljazeera State (by 11 medications) and Red Sea State (by 7 medications), with p < .001 for both comparisons [Table 5].

Table 5.

Differences in medication availability based on pharmacy type and geographic Location (n = 118).

Variation sources	Availability of critical medications
	n	Mean	SD	df	t/f	p-value
Pharmacy type
Public pharmacy	16	32.4	6.96	116	2.04	0.04*
Private pharmacy	102	28.1	8.00
Location
Aljazeera state	59	25.3	7.10	3	18.04	< 0.001*
Northern state	28	36.4	7
White Nile state	4	31.8	7
Red Sea State	27	27.7	5.03

Independent Samples t-test, and One-Way ANOVA was used.

Discussions

This study provides empirical evidence on the devastating impact of the ongoing armed conflict in Sudan on the availability of essential medicines in community pharmacies, both public and private.

The findings reveal a widespread and critical shortage of medicines, particularly in public pharmacies and in states more severely affected by the conflict. Over 95% of surveyed pharmacies reported disruptions in the availability of essential medicines, with chronic disease medications—such as insulin, antihypertensives, and antiepileptics—among the most frequently affected, alongside widespread price inflation.

Our study show that public pharmacies had a significantly higher mean availability of essential medications compared to private ones. However, private pharmacies constituted the majority of operational outlets during the study period, as many public facilities were closed due to insecurity, infrastructure damage, or staff displacement. This is consistent with broader reports of healthcare system collapse across Sudan, where only one-third of hospitals remain functional and medicine distribution has been severely impeded by violence, looting, and restricted humanitarian access^14,17,21.

The severe medicine shortages identified mirror trends reported in other conflict settings. In Syria, attacks on healthcare led to widespread supply breakdowns and chronic medication unavailability¹. Similarly, in Afghanistan and Yemen, disruptions in logistics, importation, and local production have made access to medicines for non-communicable diseases nearly impossible for large segments of the population^2,8.

Our findings also align with evidence from Gaza, Ukraine, and Ethiopia, where protracted conflict has led to long-term disruptions in medication continuity and health system resilience^23,24,26. In Sudan, the pharmaceutical supply chain has suffered a dual collapse: both upstream (e.g., closure of the National Medical Supplies Fund and loss of import capacity) and downstream (e.g., destruction of pharmacies and hospitals). Only 19 of 27 pharmaceutical manufacturers were still partially operational by late 2023, functioning far below normal capacity due to lack of raw materials, damaged infrastructure, and loss of workforce¹⁴. This collapse has resulted in a heightened reliance on expensive imports or parallel informal markets, significantly raising prices and further limiting access, especially for vulnerable populations^12,17.

The observed variability across states may be explained by geographic disparities in conflict intensity, supply routes, and local governance structures. Northern State, for instance, had significantly better availability than Aljazeera or Red Sea states, which may reflect better infrastructure, stability, or logistical connections. These disparities highlight the need for region-specific humanitarian interventions and pharmaceutical delivery strategies.

The shortage of chronic disease medications—such as insulin (only 11% availability), diazepam (15.3%), simvastatin (20.3%), and captopril (26.3%)—is particularly concerning. Interruptions in these therapies can rapidly lead to complications, hospitalizations, and mortality, as previously documented in studies of Sudanese diabetic and hypertensive patients during this conflict^15,17. Similar patterns have been reported in Ukraine and Syria, where chronic care patients were among the most affected by medicine interruptions^1,23. Additionally, the conflict has contributed to secondary health crises¹⁶.

Disrupted vaccination campaigns have contributed to outbreaks of measles and other vaccine-preventable diseases^21,22. The collapse of pharmaceutical regulation and oversight also raises concerns about counterfeit or substandard medicines entering informal supply chains, as seen in previous post-conflict environments^{6,27,28, 29}.

Implication of the study

This study highlights the critical impact of armed conflict on essential medicine availability in Sudan, revealing how infrastructure destruction, disrupted supply chains, and the collapse of local production have collectively undermined access to life-saving treatments. The findings emphasize the urgent need for coordinated humanitarian action, the restoration of secure medicine supply routes, and support for local pharmaceutical manufacturing to mitigate further health crises. By providing evidence from multiple states, this study informs policymakers, humanitarian agencies, and global health actors of the necessity to prioritize medicine access as part of emergency response efforts, ultimately aiming to reduce preventable morbidity and mortality in conflict-affected settings.

Limitations

This study was conducted under significant logistical constraints. Due to conflict-related inaccessibility, a probabilistic sampling approach could not be implemented. The final sample size of 118 pharmacies because security conditions prevented on-site visits, all data were collected via phone interviews, directly resulting in reliance on self-reported information that could not be independently verified, while meaningful, may underrepresent the most severely affected regions where data collection was not feasible. This imbalance was further magnified during the conflict as many public pharmacies were non-operational, inaccessible, or directly affected by infrastructure damage or staff displacement, whereas private pharmacies, particularly those in safer zones remained more accessible to researchers.

Additionally, the reliance on self-reported data may introduce reporting bias, particularly in estimating availability. Nonetheless, this study provides a rare and timely snapshot of medicine availability at the community level during an active conflict.

This very small sample size limits the strength of the between state comparisons and reduces confidence in the ANOVA findings.

Conclusion

The ongoing conflict in Sudan has severely disrupted the availability of essential medicines across multiple states. A combination of supply-side and demand-side barriers—including the destruction of infrastructure, shutdown of local pharmaceutical production, and sharp increases in prices—has critically undermined access to life-saving treatments. These findings highlight the urgent need for coordinated humanitarian interventions, restoration of secure supply chains, revitalization of local production capacity, and protection of remaining health facilities. National and international stakeholders must prioritize medicine accessibility as a humanitarian imperative to mitigate further preventable morbidity and mortality in Sudan.

Author contributions

We declare that all authors have made substantial contributions to the conception and design of the work, have made substantial contributions to the data acquisition, analysis, interpretation; and completed revising the results and tables. All authors have made substantial contributions to the manuscript writing, critically evaluated for important intellectual content, approved the version to be published, and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Funding

The authors did not receive any financial support for this research.

Data availability

All the data in this study are available within the manuscript.

Declarations

Competing interests

The authors declare no competing interests.

Ethical considerations

Ethical approval was obtained from the Faculty of Pharmacy, Research Ethical Committee (REC), National University - Sudan (Approval No.: FPNU-REC/013–024/12 on 20/11/2024). Participants were informed about the study’s purposes and gathered data will be confidential and used only for research purposes. Informed consent was obtained from all participants prior to filling out the questionnaire, in accordance with the Declaration of Helsinki.