OBJECTIVES: Since 2016, Sudan was transitioning from limited healthcare subsidization to universal health coverage (UHC). Increasing healthcare access was widely considered beneficial, but some worried that UHC would overwhelm clinical services. In 2020 and 2021 UHC faced the challenge of Covid-19. We undertook a review of national healthcare utilization and enrolment data in order to better understand the impact of UHC in Sudan.

METHODS: We conducted a descriptive study using National Health Insurance Fund databases. We analyzed annual enrolment, participating facilities, prescription volume and utilization from 2016 to 2021. Enrolment was stratified by employment status (government, informal sector, private sector, pensioner, impoverished). Utilization was assessed by type of care: primary, specialty, chronic disease and other; we calculated the ratio of primary to specialty care visits. We used the Mann-Kendall test for evaluating trends.

RESULTS: Participating facilities increased from 2,083 in 2016 to 3,549 in 2019, with slight contraction to 3,495 during 2020-21. Annual enrolment increased significantly, from 16.4 million in 2016 to 36.5 million in 2021 (p value < 0.01). The impoverished sector had the largest increase in enrolment (217%); informal sector had the lowest enrolment growth rate (7%). Volume of primary healthcare visits and prescriptions increased every year, except 2020, the first year of Covid-19 in Sudan. Specialty healthcare visits decreased over the same period, from 2,461,424 to 1,249,585 (p < 0.01). The ratio of primary to specialty visits increased from 6.0 in 2016 to 15.7 in 2021 (p < 0.001).

CONCLUSIONS: In Sudan, transition to UHC increased utilization of primary care services, but at a slower rate than enrolment growth. The ratio of primary to specialty visits increased and specialty visits declined, suggesting that more primary care may have prevented specialist-requiring disease states and sequelae. Fears of overwhelming the health system were unfounded indicating that other barriers to healthcare might exist.