The desktop situational analysis findings using the adapted variables from the WHO-AIMS (as shown in Table 1) are presented here. Results are presented by domain using the WHO-AIMS summary template [30].

WHO-AIMS domain 1: policy and legislative frameworkPolicies, plans and legislations

We could not identify any CAMH policy, legislation, or plans at the national or state level [19]. The Sudan National Mental Health Policy was last revised in 2009 in collaboration with the WHO and covered the following components: (1) development of mental health services in primary healthcare, (2) scaling up human resources, (3) involvement of patients and their families, (4) strengthening advocacy, (5) promotion of the human rights protection of patients, (6) equity and access to mental healthcare services across different groups, (7) quality improvement, (8) financing and (9) establishing monitoring systems [20]. The policy was developed by a committee that included representatives from different Sudanese universities, Federal and States Ministries of Health, and the Ministry of Social Affairs. There were no stand-alone or CAMH-specific policies or plans identified. However, in the Sudan Mental Health Policy, CAMH was mentioned under specialized programmes that need to be developed together with addiction and old age psychiatry. Despite the absence of legislation specific to CAMH, the Children’s Act (2010), released by the National Council for Child Welfare under the supervision of the Ministry of Justice in 2010, represented legislation relevant to children under the age of 18 years and laid the foundation for child protection and welfare in Sudan. The act was considered important legislation that addressed the issues of children’s need for protection, care, safety, and justice; and defined the child and the age of criminal responsibility. The act did not specify how these concepts should be applied [31].

Human right relevant to children and adolescents

Despite the human rights domain being mentioned in the Sudan Mental Health Policy [19], no human rights review body existed in Sudan during this situational analysis. At the country level, the Psychiatry Consultancy Board (PCB), a body consisting of senior mental health professionals in the county and directly related to the Sudanese Federal Ministry of Health, provided advice to the government related to human rights, legislation, service coordination, and planning. However, the PCB was not involved in any executive decision-making [Personal communication, Dr Salah Haroun, Previous head of the PCB, 29 Nov 2021]. In Khartoum, there was no reported review or inspection of the human rights protection of children and adolescents during the situational analysis period, either in mental health facilities or in community-based services. Furthermore, we found no evidence that mental hospital staff or staff working in inpatient psychiatric units or community residential facilities had received teaching or training sessions on the human rights protection of patients during the study period [Personal communication, Medical directors of the psychiatric facilities in Khartoum, 13 December 2021].

Expenditure on CAMH services in Khartoum

The situational analysis was not able to identify any data related to the financing of mental health or CAMH in Khartoum. About 6.5% of Sudan’s Gross Domestic Product (% GDP) and 8.2% of the general government expenditure on health in general. The out-of-pocket share was about 70% (US$84.0 per capita), while the general government health expenditure represents only 22.3% (US$26.9 per capita) [32].

WHO-AIMS domain 2: child and adolescent mental health servicesExistence and functions of a regional CAMH authority

As outlined under domain 1, a PCB existed at Federal Level, but no health authority in the country was devoted to overseeing CAMH. In practice, the directors of the psychiatric hospitals functioned as leading authorities for mental health in their facilities [Personal communication, Previous head of the PCB, Dr Salah Haroun, 29 Nov 2021]. However, these facilities typically did not include many children and adolescent mental health specialists.

Organization of CAMH services in terms of catchment areas

The mental health service provision in Khartoum state was under the umbrella of the directorates of curative medicine [19]. Theoretically, mental health services in Khartoum were organized in terms of geographical (i.e., catchment areas) service areas. However, the structure was strongly centralized [18]. Khartoum state was divided into three major cities, Khartoum, Omdurman, and Bahri. Each city was further divided into localities, with a total of seven localities in the whole of Khartoum state.

Availability of CAMH outpatient facilities, and number/proportion of children and adolescents treated for mental health problems through outpatient facilities at primary, secondary, and tertiary levels of care

We were unable to find any publicly available data about CAMH services in Khartoum. However, on the ground, CAMH services were available in three specialist mental and paediatric health facilities in Khartoum, distributed in two cities of Khartoum state (two in Omdurman, one in Bahari). The first service was a weekly outpatient service for children with mental health problems established as a package of care through the Department of Paediatrics at the Military hospital in 1998 and supervised by a child psychiatrist. The second service was also an outpatient and inpatient service for children and adolescents with mental health problems based in a Taha Baashar psychiatric hospital in Bahri, established in 2011 and supervised by a child psychiatrist. Inpatient care for children was provided in an adult mental health ward. The third service for children and adolescents with mental health problems was in the Alzahra centre (a mother-and-child unit) in the Eltigani Elmahi Psychiatric hospital in Omdurman. This centre provided outpatient (3 days per week) and inpatient services for children and adolescents with mental health problems (in a separate two-bed ward). The centre was established in 2015 and was supervised by a general psychiatrist interested in childhood psychiatric disorders. According to data from health facilities that ran CAMH services, 980 children and adolescents were seen during the study period from January 2019 to December 2020. Out of all children and adolescents treated as outpatients in these facilities, 27.55% (N = 270) were female. Further details are shown in Table 2.

Table 2 The number and percentage of children and adolescents seen at the different mental health outpatient facilities during the study period in Khartoum state

The data from the specialist facilities that provided CAMH services revealed the most frequently diagnosed disorders (from the most to the least frequent) in the outpatient clinics of Khartoum during the study period were: (1) unspecified psychological and behavioural conditions, (2) intellectual disability, (3) epilepsy, (4) attention deficit hyperactivity disorder, (5) schizophrenia and related psychotic disorders, (6) autism spectrum disorder, and (7) disruptive behaviour disorders. These diagnoses were based on the outpatient facilities registry in the three hospitals that provided mental disorders services for children and adolescents. The average number of hospital/clinic contacts per user was not available. There was no organized follow-up care in the community for the individuals seen at outpatient facilities that provide CAMH services. All three outpatient facilities had access to non-medical treatments such as occupational therapy, speech and language therapy, and psychological therapies. There were no available data about the type of psychological intervention specific to children and adolescents with mental health problems. Furthermore, whenever specialized psychotherapies (i.e., psychotherapy for OCD, Tic disorder, behavioural interventions for autism etc.) were needed, patients and their families were referred to private clinics, which mostly provided CBT-informed therapies.

Availability of CAMH inpatient facilities and number/proportion of children and adolescents treated

At the time of the situational analysis, there were three general adult psychiatric hospitals in Khartoum, with a total of 146 beds (Male = 94; Female = 52), representing 2.9 beds per 100,000 of the Khartoum population [17]. All of these facilities were organizationally integrated with mental health outpatient facilities. No beds in general psychiatry hospitals were dedicated only to children or adolescents during the study period from January 2019 to December 2020. Therefore, if admission was needed for a pre-adolescent (child), admission was to the female ward. Adolescents were admitted to a male ward. It is also important to mention that the admission of children and adolescents to these facilities was voluntary. Based on data from the registry of facilities that provided services for CAMH services, children and adolescents admitted to mental hospitals were primarily from four diagnostic groups: (1) unspecified psychological and behavioural disorders, (2) psychiatric disorders due to underlying medical conditions, (3) schizophrenia and related psychotic disorders, and (4) mood disorders. The average number of days spent in mental hospitals was not stated. However, informal data from practising clinicians working in CAMH facilities suggested that the admission period typically lasted between 7 and 14 days [Personal communication, Dr Emad Elsunni, Dr Mohja Ibrahim, and Dr Lubaba Abdalla, psychiatrists at Taha Baashar and Eltigani Elmahi Psychiatric Hospitals, 12 December 2021]. There were no CAMH day patient facilities, community residential facilities, forensic facilities, or CAMH hospitals in Khartoum state during the study period. The details of inpatients admitted to the facilities that provided CAMH services were available in Taha Baashar hospital, as presented in Table 3. Unfortunately, the number and percentages of inpatients below 18 years admitted with a mental health problem in the Military and Eltigani Elmahi hospitals could not be identified.

Table 3 The number of children and adolescents treated as inpatients at Taha Baashar Hospital in Khartoum in 2019 and 2020Interventions (Medications): Psychotropic medicines appropriate for children and adolescents are included on the essential medicines list, and free access to essential psychotropic medicines, and availability of medicines in outpatient and inpatient settings at secondary and tertiary levels of care

Regarding the availability of psychotropic medicines, the supply in the country was interrupted in 2019 and 2020 due to a combination of the COVID-19 pandemic, an unstable economy, and the political situation in the country [33]. Despite these challenges, facilities that provide mental health services for children and adolescents had at least one psychotropic medicine of each therapeutic class relevant to children and adolescents (antipsychotic, antidepressant, mood stabilizer, anxiolytic, and antiepileptic medicines). However, medications used for ADHD (i.e., methylphenidate) were classified in the Sudan Essential Medicines List in the category of drugs prescribed by specialists service. Hence it was available only in three pharmacies in Khartoum state [Personal communication, Dr Samah, Pharmacist at Taha Baashar Hospital, 13 December 2021]. Health insurance was available and provided by different insurance companies, however, the percentage of children and adolescents covered was not clear.

According to the National Essential Medicines List (2014), three medications were listed in the child psychiatry category. These included atomoxetine (a non-stimulant medication for ADHD), methylphenidate (a stimulant medication for ADHD), and clonazepam (a benzodiazepine). There were no antidepressant, anti-anxiety, or antipsychotic medications for children included in the essential medicines list category during the study period. However, other medications used in CAMH were included under general psychotropic medicines (e.g., risperidone, clozapine, fluoxetine, sertraline, imipramine, valproic acid, lithium, carbamazepine and lorazepam). Methylphenidate was a controlled medication that was classified in the list of essential medicines as “medicines used by specialized centres and units in some designated hospitals” and was only available in National Medical Supplies Fund pharmacies [34]. The Sudan Nation Supply Fund was established in 1935 as a central drug store affiliated with the Federal Ministry of Health. The main objectives were to increase coverage of essential and affordable medicines and prevention of the distribution of medicines from unreliable sources [34].

WHO-AIMS domain 3: child and adolescent mental health in primary healthcareRefresher training in CAMH provided to primary health care (PHC) doctors, nurses or other staff and interaction of PHC with specialist CAMHS

During the study period, the team could not identify information about CAMH at the primary care (PHC) level in Khartoum. However, in a WHO report on mental health in Sudan, clinics in primary care were described as both physician-based and non-physician-based [20]. The majority (> 80%) had no assessment or treatment protocols for key mental health conditions available. They could diagnose and treat some psychiatric disorders in adults (e.g., depression, bipolar disorders, psychotic disorders). No data were available regarding mental health problems in children and adolescents [20]. The majority of the primary health care clinics (51–80%) made at least one monthly referral to a mental health professional. There was no mention of a referral process or whether it included a referral to specialized facilities that provide mental health services to children and adolescents. There was no clear communication process between primary care physicians and mental health professionals regarding individuals with mental disorders, including children and adolescents [20]. Interestingly, a School Mental Health Programme, a part of the school health programme, was represented in eight primary health care clinics geographically distributed in the Khartoum state localities (see Fig. 2). The programme was supervised by the Khartoum Ministry of Health (the School Health Directorate) in collaboration with the Khartoum Ministry of Education. The school mental health clinics, established in 1998, provided mental health services to school-aged children. Unfortunately, we were not able to identify any specific numbers for children and adolescents seen during the study period. The programme included a package of early detection, intervention, management, and follow-up for school-age children with various psychiatric disorders. The process started with a mobile team (that included medical doctors, psychologists, dental care specialists, audiologists, and nutritionists), providing basic health education (including mental health) to teachers and students in all the government schools in Khartoum. Then a focal person (either a teacher or an educational psychologist) would then be allocated to report children at risk and children with symptoms of mental health problems. After that, the caregiver of a child with a mental health problem would be given a referral form to be seen in the nearest school mental health clinic. If further referral to a higher level of specialized services was needed, the process was unclear. In the SMH clinics, the staff included mainly psychologists. No psychiatric doctors were included since 2018 [Personal communication, Mrs Asma, coordinator of the SMH program, 12 January 2022]. Before 2019, psychiatry specialists used to see children with mental health problems twice weekly at SMH clinics. Most psychiatric doctors in the SMH programme were part-timers and resigned because of low payment [Personal communication, Dr Safa Elsarrg and Dr Bahja Hamed, psychiatrists who worked in SMH clinics, 10 December 2021].

The situational analysis also identified centres for traditional healing in the community, not regulated by the Ministry of Health [20]. They provided religious, spiritual, and cultural healing for their client, including children and adolescents, without basic mental health training. We were not able to find data about the number of clients, types of interventions, outcomes and feedback about these centres.

Fig. 2

The figure shows the distribution of the school mental health clinics in Khartoum state

We were not able to find data regarding refresher training on CAMH for doctors, nurses, or other staff provided at the primary healthcare level in Khartoum state during the study period. The last time practitioners at the primary care level received a comprehensive training course in mental health was in 2016 and organized by the Khartoum Ministry of Health and included primary care trainees. The training programme included topics on child and adolescent mental health [Personal communication, Dr Amal Eltigani, Psychiatrist, the Director of Eltigani Elmahi Hospital and mhGAP trainer, 10 February 2022].

Availability of medicines and psychosocial interventions in PHC facilities

In Sudan, medically-qualified and non-medically qualified primary health care workers (referred to as ‘medical assistants’) can prescribe basic psychotropic medications to children and adolescents that are classified under categories AA, A, and B in the essential medicines list (i.e., medicines that used in health facilities run by community worker, medical assistants, and medical doctors) [35]. This included imipramine, amitriptyline, clomipramine, carbamazepine, and diazepam. The use of psychotropic medications for children with mental health problems by primary care providers was not clearly stated. Stimulants and non-stimulant medications for ADHD were only prescribed in a specialist services/ unit. In real-life practice, primary health care providers could prescribe a wide range of psychotropic medications to children and adolescents (e.g., fluoxetine, sertraline, risperidone, and olanzapine) without restrictions, except for stimulant medications, as outlined earlier. As for the availability of psychotropic medicines, most physician-based PHC centres had at least one psychotropic medicine of each therapeutic category (antipsychotic, antidepressant, mood stabilizer, anxiolytic, and antiepileptic) either in the facility or a nearby private pharmacy (which worked independently from the government sector). Medications were not provided free of charge except in the case of psychiatric emergencies, and the cost of the cheapest antipsychotic medication represented approximately 27% of the minimum daily wage, and the cost of the cheapest antidepressant medication ~ 18% of the minimum daily wage [20, 35]. There were no differences in the prices of psychotropic medication between the primary and specialist mental health services for children and adolescents.

WHO-AIMS domain 4: human resourcesHuman resources in CAMH services

The WHO estimated the total number of human resources working in mental health facilities in Sudan to be 0.92 per 100,000 population [20]. The total number of workforces in the mental health facilities that provide care for children and adolescents in Khartoum was estimated to be 0.1 per 100,000 population during the study period. No formal human resource data were available for CAMH during the situational analysis period. However, as shown in Table 4, informal data suggested that 26 mental health professionals were working in facilities that provide services for children and adolescents [Personal communication from the three Psychiatric Hospital Directors and the coordinator of the SMH programme, 23 December 2021]. The two child psychiatrists worked both for government-administered CAMH facilities and in the private sector. The psychologists, social workers, and nurses worked for government-administered mental health facilities, either exclusively or also in other sectors.

Table 4 Informal estimate of the number and specialities of the mental health workforce who provided services for children and adolescents in Khartoum in 2019 and 2020WHO-AIMS domain 5: public education and links with other sectorsPublic education and awareness campaigns about CAMH

There were no coordinated bodies at the Federal and State Ministries of Health to oversee public education and awareness-raising campaigns specific to CAMH in Khartoum state during the study period. As a result, we were not able to identify any awareness-raising programmes specific to CAMH in Khartoum state during the study period. However, different non-governmental organisations (NGOs), professional associations, private trusts/foundations, and international agencies have promoted public education and awareness campaigns during the study period [20]. These campaigns targeted the general population, children, adolescents, women, and trauma survivors, e.g. gender-based violence.

Regarding the link and the collaboration between Health and other sectors in Khartoum, there were formal collaborations with the departments/agencies responsible for primary health care, child and family protection, education, and social affairs [35]. However, as stated earlier, the link was poorly defined.

WHO-AIMS domain 6: monitoring and researchData transmission from mental health facilities and Reports on mental health services by the government health department

The Sudanese Health Information System (HIS) was one of the first information systems in the region [15]. It involved data collection, processing, analysis, and dissemination. Data in the health sector in Sudan is collected by individual health facilities and communicated to the State and Federal Ministries of Health. The information obtained was used to produce periodic reports, make decisions, allocate resources, and monitor the plans and strategies [36]. Unfortunately, the HIS had various weaknesses in which information collected was not pooled into the HIS, and some facilities collected and used data for their activities and then stopped without disseminating their findings [37]. In addition, there was an overall limited capacity for the analysis, utilization, and dissemination of data and findings [38]. There was no formally defined list of individual data items related to CAMH problems to be collected by all mental health facilities, as evident by the type of data from different facilities [Personal communication from the Head of HIS Department at the Khartoum Ministry of Health, 17 January 2022]. Instead, different mental health facilities registered different data related to CAMH (as shown earlier in Tables 3 and 4). These included the number of outpatient clinics per week, the number of patients seen in the facilities, diagnoses, and age ranges [Data department in Bashaar, Eltigani Elmahi, and the Military hospitals, 2021]. Furthermore, no formal reports were produced using the data transmitted to the Government Health Department [Personal communication from the Head of HIS Department at the Khartoum Ministry of Health, 17 January 2022].

Research in CAMH

In order to generate an overview of research relevant to child and adolescent mental health in Khartoum, we performed a data search for all relevant publications over ten years, including the two years of this situational analysis (2010–2020). Anticipating a low yield of peer-reviewed literature, we performed a broad online search on PubMed and Google scholar using “child and adolescent,” “mental health,” “Khartoum state,” and “Sudan” as keywords. In addition, we asked local mental health experts (psychiatric doctors and psychologists) working in Khartoum hospitals to identify any potentially relevant publications in the peer-reviewed and grey literature (including dissertations, reports, and non-peer-reviewed journals). As a result, a total of 11 articles were identified, as shown and described by study themes in Table 5. Six of the identified articles were about trauma and stress-related disorders, two were about neurodevelopmental disorders and disruptive behaviours, and one was about CAMH training in the middle-east region [20, 22, 38,39,40,41,42,43,44,45,46]. Furthermore, 90% (N = 10) of the identified research were conducted by Sudanese researchers.

Table 5 Research on CAMH in Khartoum state, Sudan between 2010–2020