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

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.

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.

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.

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.