Factors influencing primary care guideline implementation and adherence in Sudan: a qualitative study

Abstract

Introduction

The Sudanese healthcare system faces multiple challenges, including increasing patient loads, shortages of medical supplies, economic instability, and inequitable distribution of healthcare services. Clinical practice guidelines (CPGs) can improve patient outcomes and support efficient use of limited resources. This study explored factors affecting the implementation and adherence to CPGs in primary healthcare settings in Sudan.

Methods

This paper presents a secondary analysis of qualitative data collected as part of a larger quantitative study. The parent study employed a cross-sectional study design using a structured questionnaire to collect quantitative data on Clinical Practice Guideline implementation and adherence in primary healthcare settings in Sudan. For the purposes of this secondary analysis, we analysed the qualitative components of the parent study, which included open-ended questions and free-text responses. The parent study was conducted in public referral primary healthcare (PHC) centers in Khartoum and Gezira States, Sudan. The study population included family medicine doctors and medical directors working in referral PHC centers. A total of 76 family medicine doctors participated. Data were collected through eight focus group discussions and four in-depth interviews, which were audio-recorded and analysed using thematic content analysis.

Results

Participants reported limited availability, poor dissemination, and infrequent updating of local Sudanese guidelines, leading to reliance on international guidelines that were often difficult to implement because of resource limitations. Training opportunities for family medicine doctors were reported to have declined due to political and economic instability and the impact of the COVID-19 pandemic. Major barriers to CPG implementation included limited health insurance coverage, patients’ low socioeconomic status, high workload, insufficient training opportunities, and weak filing and referral systems. Marked regional inequities were identified, particularly in Gezira State, where participants described deterioration in family medicine services, collapse of telemedicine and electronic filing systems, poor infrastructure, and restrictive health insurance policies limiting physicians’ scope of practice.

Conclusion

The implementation of CPGs in Sudan is hindered by multiple systemic, financial, and organizational barriers, including limited access to updated local guidelines, inadequate training, weak health insurance coverage, and poor healthcare infrastructure. Political and economic instability and regional inequities, particularly in Gezira State, further contribute to challenges in evidence-based primary healthcare practice in Sudan.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12875-026-03503-2.

Introduction

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 significant potential to improve the quality of healthcare and health practice outcomes by minimizing inconsistencies in clinical practice. They are viewed by national health stakeholders not just as critical instruments for providing effective and efficient treatment, but also as increasingly essential in transferring the rapid flow of research findings into practical clinical applications [2].

Health system in Sudan

The Federal Ministry of Health (FMOH) in Sudan is responsible for 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 planning, provision of secondary and tertiary services, and financial and technical support to the localities. Each locality is responsible for primary health care (PHC) service delivery and community services [3].

There are 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.

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 attributed to fragmentation in the health system, an inefficient financing system, irrational use of medicine and technology, mismanagement of human resources, and a lack of quality indicators. Health services coverage is 86%, with a greater focus on curative rather than preventive care, and on secondary and tertiary care rather than primary care [3].

In Sudan, despite many efforts and resources being invested to improve clinical practice, adherence to and implementation of CPGs remains suboptimal due to financial, professional, and political constraints [4]. Moreover, practicing doctors face difficulties customizing international guidelines to the Sudanese context [4, 5]. This highlights the need for the regular development of local protocols tailored 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 factors at the organizational and 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 a crucial component in the development and implementation of CPGs, whether in the formulation of clinical questions, reviewing the final documents, or suggesting strategies to identify, specify, and prioritize implementation strategies [10]. They contribute essential insights into implementation factors, such as detailed knowledge of processes, organizational structure, culture, available resources, and other challenges 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 increasing interest in stakeholder engagement in CPGs, the perspectives of key stakeholders such as healthcare providers, policymakers, and health administrators regarding the acceptance, development, and implementation of CPGs remain underexplored regionally, particularly in Sudan [12]. Therefore, this study aimed to explore the main factors affecting CPG implementation and adherence within the Sudanese health system.

Methods

Study design

This paper presents a secondary analysis of qualitative data collected as part of a larger quantitative study [4]. The parent study was a quantitative cross-sectional study that employed a structured questionnaire to comprehensively explore factors affecting CPG implementation and adherence in Sudanese primary healthcare settings. The parent study examined a broad range of factors including availability and quality of local guidelines, training opportunities, health insurance constraints, and regional disparities between Khartoum and Gezira States. For the purposes of this secondary analysis, we analysed the qualitative components of the parent study, which included open-ended questions and free-text responses collected through focus group discussions and semi-structured interviews alongside the quantitative data. The parent study was conducted in public referral primary health care centers (PHCCs) in Khartoum and Gezira States, Sudan, between April and December 2021.

Study population

The study population comprised practicing family medicine doctors and medical directors of referral PHCCs. A purposive sample of eight PHCCs was selected (four in each state). A total of 76 family medicine doctors participated.

Data collection and data analysis

Data were collected over one month using focus group discussions (FGDs) and semi-structured in-depth interviews. Eight FGDs (four per state), each comprising 8–10 doctors, were conducted. In addition, four semi-structured in-depth interviews were carried out with family medicine doctors serving as medical directors.

The FGDs and interviews were facilitated by the principal investigator, while a trained research assistant was responsible for note-taking and logistical support under the supervision of research fellows. A semi-structured interview guide [Annex 2] was used to explore barriers and facilitators related to Clinical Practice Guideline (CPG) implementation and adherence.

All sessions were audio-recorded with participants’ consent and supplemented by field notes. Each focus group discussion lasted approximately 60 min on average, while in-depth interviews ranged from 30 to 45 min. Audio recordings were transcribed verbatim and anonymized prior to analysis.

Data analysis employed an inductive thematic content analysis approach, allowing themes to emerge from the data rather than being predetermined by existing frameworks. This approach was chosen to capture the full range of participants’ experiences and perspectives without imposing external categorizations. Two researchers independently reviewed all transcripts and performed open coding to identify initial concepts and recurring patterns. Through an iterative process, initial codes were grouped into preliminary categories. The research team held regular meetings to discuss emerging categories and refine them into broader themes. Themes were developed by examining patterns across participants’ responses and identifying commonalities in their experiences. The final thematic structure was achieved through consensus among all team members.

Disagreements between coders were resolved through discussion and consensus-building. When differences in interpretation arose, the researchers returned to the original transcripts, reviewed the relevant passages in context, and discussed their interpretations until agreement was reached. In cases where consensus could not be achieved through discussion, a third researcher was consulted to provide an independent perspective. Frequencies of code occurrence were not calculated, as this study employed a purely qualitative approach focused on understanding the range and depth of participants’ experiences rather than quantifying response patterns.

Several strategies were employed to enhance the trustworthiness and rigor of the analysis. First, data triangulation was achieved through the inclusion of both focus group discussions and in-depth interviews, providing multiple perspectives on the same phenomena. Second, investigator triangulation involved two researchers independently analysing the data. Third, member checking was conducted by presenting preliminary findings to a subset of participants to verify that the themes accurately reflected their experiences. Fourth, reflexive practices were maintained throughout the research process, with researchers documenting their assumptions and potential biases. Fifth, thick description of the context and participants’ experiences was provided to enable readers to assess the transferability of findings to other settings. Finally, an audit trail was maintained, documenting all analytical decisions and revisions made throughout the research process.

The depth and richness of data were ensured through several strategies. First, the focus group discussions, lasting approximately 60 min each, allowed for sustained exploration of topics and interaction among participants, which often stimulated deeper reflection and elaboration of experiences. Second, the semi-structured interview guide included open-ended questions and probes that encouraged participants to provide detailed accounts of their experiences. Third, the inclusion of both group discussions and individual interviews allowed participants to share perspectives in different settings, with some participants more comfortable sharing in group settings while others preferred one-on-one interactions. Fourth, field notes were taken during each session to capture non-verbal cues and contextual details that enriched the data. Finally, data saturation was achieved, as no new themes emerged in the later FGDs and interviews, indicating that sufficient depth had been obtained.

Consistent with qualitative research conventions, we have refrained from quantifying responses. Instead, we use qualitative descriptors to convey the relative frequency of themes while acknowledging that our sampling strategy was designed for depth of understanding rather than statistical generalizability.

Ethical approval

Ethical approval was obtained from the authorized ethical committee of the Federal Ministry of Health (FMOH). Permission was secured from the directors of the participating PHCCs. Written informed consent was obtained from all participants after explaining the study’s purpose. Confidentiality and privacy were maintained throughout data collection, analysis, and reporting.

Results

Qualitative findings from focus group discussions and in-depth interviews

The analysis of the focus group discussions and interviews revealed several overarching themes regarding the implementation of CPGs in Sudan, encompassing the state of local guidelines, training, systemic barriers, and regional disparities.

Availability and Quality of Local Guidelines

A predominant concern among participants was the absence of comprehensive Sudanese guidelines covering common medical conditions. Furthermore, existing local guidelines were criticized for their poor dissemination and infrequent updates. Participants recommended wider distribution of guidelines through social media and posters within PHC centers to improve accessibility.

The reliance on international guidelines was problematic. As one doctor noted, “The international guidelines must be modified to suit the local settings… Some are difficult to implement due to cost and unavailability of drugs and investigations in distant and rural areas.”

Another participant highlighted issues with trust in local adaptations, stating, “The local Sudanese guidelines recommendations sometimes differ from international ones… This is due to an absence of evidence-based studies and good publication.” A common sentiment was summarized by a third doctor: “Generally, there is no obvious regular updating of the local guidelines… The only guideline that is regularly updated is the malaria protocol because it is funded by the World Health Organization (WHO).”

Training and Capacity Building for Family Medicine Doctors

While Ministry of Health-regulated training programs for family doctors were acknowledged, participants reported a significant decline in these opportunities, exacerbated by political instability and the COVID-19 pandemic. The frequency of existing programs was deemed insufficient to cover all necessary topics, and access was not equitably distributed, with doctors in Gezira State reporting fewer opportunities than those in Khartoum. One participant expressed a common need: “The workshops occur, but doctors require more training programs… they tend to cover only chronic diseases and do not occur regularly.”

Systemic, Provider-, and Patient-Level Challenges Affecting CPG Implementation

Participants identified multiple interconnected challenges affecting the implementation of Clinical Practice Guidelines (CPGs) within the Sudanese healthcare system. Financial and systemic barriers were the most frequently reported concerns, with the overwhelming majority of participants highlighting limited health insurance coverage and patients’ low socioeconomic status as major obstacles to guideline adherence. Many participants also emphasized the influence of the broader economic and political instability in Sudan on healthcare delivery and access to recommended treatments.

Several participants identified provider- and system-related challenges, including high patient workload, insufficient regular training opportunities, and the absence of effective filing and referral systems. Figure (1) summarizes the main barriers reported by participants.

Fig. 1.

Main barriers to clinical practice guideline implementation identified by participants in focus group discussions and in-depth interviews (qualitative thematic summary)

One participant explained: “There are many factors that impede guideline implementation… including limited health insurance services and patients’ low economic status. Also, the economic and political situations in Sudan play an important role.”

The critical role of health insurance

The limited scope of governmental health insurance—covering only routine investigations and less expensive drugs—was a major operational hurdle. This impedes guideline implementation by forcing clinicians to omit essential investigations and prescribe second- or third-line treatments. A doctor stated, “Due to the economic situations, we can’t prescribe certain treatments or order recommended investigations… sometimes we prescribe the second-line treatment.” A critical disparity was noted in Gezira State, where family medicine registrars are classified as medical officers and are restricted to using the “black form,” limiting their prescribing power. In contrast, their counterparts in Khartoum use the “red form,” which grants them the full scope of practice of a specialist.

Deterioration of Family Medicine Practice in Gezira State

A stark finding was the reported decline of family medicine services in Gezira State. Previously supported by external funding, the state had successfully implemented an electronic filing system, telemedicine for specialist consultations, and home care programs. These initiatives have since collapsed. Participants attributed this deterioration to governmental neglect and potential political issues, expressing a strong sense of loss. The physical infrastructure of PHC centers was also described as inadequate, lacking essential departments and staff compared to Khartoum. This often forces unnecessary referrals for basic investigations. The frustration was palpable in one quote: “Family medicine registrars are not allowed to use the red form… This forces us to refer our patients to the specialist just to prescribe a medication like ‘Amoclan’, and this reflects badly on the patients as well…… We hope the situation can change for the better.”

Table (1) presents an overview of the key themes, subthemes, and representative quotes.

Table 1.

Summary of Main Themes, Subthemes, and Exemplar Quotes

Main Theme	Subthemes	Exemplar Quotes
Availability and Quality of Local Guidelines	- Absence of comprehensive Sudanese guidelines - Lack of regular updates - Poor dissemination and accessibility	“The international guidelines must be modified to suit the local settings of Sudan… Some are difficult to implement due to cost and unavailability of drugs.” “…We just heard about the Sudanese hypertension guidelines, but we have never seen it.”
Training and Capacity Building	- Reduced training opportunities - Unequal access across states - COVID-19 and political instability affecting CME programs	“The workshops occur, but doctors require more training programs… they tend to cover only chronic diseases and do not occur regularly.”
Barriers to Guidelines Implementation	- Limited health insurance coverage - Patients’ financial constraints - Lack of filing and referral systems - High workload	“There are many factors that impede guideline implementation, including limited health insurance services and patients’ low economic status.”
Health Insurance Constraints	- Limited coverage of drugs and investigations - Inconsistent policies across states - Doctors forced to use second-line treatments	“Due to economic situations, we can’t prescribe certain treatment or order investigations… sometimes we prescribe the second-line treatment.”
Deterioration of Family Medicine Practice in Gezira State	- Collapse of telemedicine and electronic filing - Poor infrastructure and resource inequity - Restrictive NHIF policies	“Family medicine registrars are not allowed to use the red form… we refer patients just to prescribe medication like ‘Amoclan’.”
Systemic and Political Factors	- Economic instability - Unequal health system between Khartoum and Gezira - Governance and policy issues	“The deterioration resulted from economic and political situations and inequality in government plans and health insurance strategies.”

Discussion

The study demonstrated high adherence to and implementation of the guidelines. However, the accessibility and regular updating of local Sudanese guidelines require improvement. These findings align with Abdelgadir et al., who also reported high implementation rates alongside inadequate dissemination of Sudanese guidelines [4, 5].

The implementation of guidelines in Sudan is constrained primarily by inadequate health insurance coverage and patients’ low economic status. These factors compel practitioners to deviate from guideline recommendations and base clinical decisions on the availability of medications and investigations rather than best practices. Additional systemic barriers include a shortage of healthcare workers, a lack of training programs, and an ineffective filing system. The geographical distribution of referral PHC centers, the availability of essential diagnostics, and comprehensive health insurance are all critical factors for improving the quality of care. This finding is supported by Abdelgadir et al., who also highlighted the restrictive nature of health insurance services in Sudan [4]. Ultimately, the accessibility of services, patient-related factors, and the broader economic context significantly influence clinical decision-making and guideline adherence [4, 5].

This study also documented a reduction in regulated training programs, largely attributable to political instability. The qualitative data further underscored the limited coverage provided by the National Health Insurance Fund (NHIF), particularly in Gezira State, and highlighted the poor infrastructure of many PHC centers. These findings are consistent with those of Abdelgadir et al. and Nurelhuda et al., confirming that economic challenges are a primary driver of health system deterioration and inequity in Sudan [4, 13]. These issues are exacerbated in rural areas, which suffer from a critical shortage of qualified doctors and support staff. Consequently, encouraging junior doctors and residents to work in remote areas remains a key global policy recommendation [3, 14].

In summary, guideline implementation in Sudan is impeded by a confluence of factors: limited financial and medical resources, poor infrastructure, and insufficient staffing. The country’s economic decline has led to a deterioration in the quality of medical supplies and reduced funding for health system reconstruction. Furthermore, the emigration of doctors seeking better salaries and working conditions—a significant brain drain—further weakens the system. These multifaceted barriers to guideline implementation are well-documented in the literature [15, 16].

A notable decline in family medicine practice was observed in Gezira State, driven by economic pressures, political instability, and disjointed governmental and health insurance strategies. Compounding this issue, specific policies from the NHIF and the State MOH undermine family medicine doctors by categorizing them as medical officers, which limits their scope of practice. This regional disparity exemplifies the broader inequalities reported in the Sudan national health policy, which notes significant variations in health system funding and resources not only between states but also between urban and rural areas within them [3].

While the parent study [4] identified similar barriers through quantitative methods, our secondary qualitative analysis extends these findings by illuminating the interconnected nature of these barriers across individual, organizational, and system levels, and by providing a more detailed examination of regional policy disparities and their implications for clinical practice through participants’ own narratives and experiences.

Strengths and limitations of the study

This study has several notable strengths. The research team possessed significant expertise in qualitative methods, deep knowledge of CPGs, and proven skills in stakeholder engagement. Furthermore, the multidisciplinary composition of the team—which included clinicians, academics, family medicine and public health consultants from both State and Federal Ministries of Health—enriched the analysis by providing diverse perspectives and identifying critical gaps in the guideline implementation process.

A primary limitation, however, is the study’s scope, which focused exclusively on healthcare providers and administrative authorities. The perspectives of patients, who are essential stakeholders and active agents in their own care, were not included. Their lived experience and insights represent a crucial dimension for understanding barriers to adherence and co-designing effective implementation strategies, and thus their omission marks an important area for future research.

Conclusion

The primary health care system in Sudan has faced persistent challenges since its establishment, rooted in political instability and economic constraints. This study identifies limited health insurance coverage, patient-related factors, and the unavailability of services as critical barriers to Clinical Practice Guideline (CPG) implementation. These factors compel practitioners to deviate from evidence-based recommendations due to service costs, resource shortages, and patient circumstances.

A notable finding is the disproportionate decline of the health system in Gezira State. A once-promising telemedicine program, initiated there at the PHC level, has been discontinued, and family medicine practice has markedly deteriorated. This decline is attributed to broader economic pressures and inequitable distribution of resources and focus, which have favored the capital, Khartoum. Furthermore, divergent state-level health policies have resulted in differing scopes of practice for family medicine between Khartoum and Gezira States. These policy differences have created significant operational disparities for family physicians in the two states.

Therefore, addressing these challenges requires a multi-faceted approach focused on expanding health insurance, ensuring equitable resource distribution, and developing locally tailored guidelines to bridge the gap between evidence and practice across all regions of Sudan.

Recommendations

Based on the findings of this study, several key recommendations are proposed to strengthen the primary healthcare system in Sudan. To address fundamental financial barriers, the government, represented by the NHIF, should prioritize the expansion of health insurance coverage to include a wider range of essential drugs and diagnostic services. Concurrently, the Federal Ministry of Health, in collaboration with the Sudan Medical Specialization Board (SMSB), needs to revitalize and expand regulated Continuing Medical Education (CME) and Continuing Professional Development (CPD) programs for family medicine doctors. It is crucial that these training opportunities are equitably distributed across all states, with specific strategies to address geographical disparities between urban and rural areas.

To enhance the quality of care, we recommend the systematic implementation of regular clinical audits and evaluations within primary health care centers. Furthermore, State Ministries of Health (SMOH) are strongly encouraged to provide sustained support to professional societies for the development, dissemination, and regular updating of evidence-based national Sudanese guidelines. Regarding health system infrastructure, urgent attention should be given to re-establishing the electronic filing system and telemedicine services in Gezira State, with a view to expanding this successful model to Khartoum and across the nation. A critical step towards empowering healthcare workers involves the revision of NHIF and SMOH policies in Gezira State that currently restrict family medicine registrars from using the “red form,” thereby allowing them to practice to their full professional capacity.

Finally, for the sustainable implementation of Clinical Practice Guidelines, a rigorous, multidisciplinary approach involving all key stakeholders is recommended for their development. This should be supported by a comprehensive national dissemination strategy that utilizes scientific journals, local peer networks, and trained colleagues. We also urge policymakers to consider establishing a dedicated national body responsible for coordinating CPGs, managing conflicts of interest, and ensuring continuous quality assurance and control throughout the health system.

Abbreviations

AICS

Agency for Italian Cooperation

CPGs

Clinical Practice Guidelines

CME

Continuing Medical Education

CPD

Continuing Professional Development

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

WHO

World Health Organization

Authors’ contributions

Hiba Salah: Designed and implemented the study protocol and 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 and 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: Participated in data analysis , proofread and edited the final manuscript.All authors read and approved the final version of the manuscript before submission.

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 (NPHI).

Data availability

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

Declarations

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 obtained from all participants with assurance of confidentiality and all their rights. The purpose of the study was explained briefly. Confidentiality and privacy were maintained during data collection, analysis, and reporting.

Consent to publish

Not applicable.

Competing interests

The authors declare no competing interests.