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 countries1,2,3,4,5,6. Armed conflict is a particularly devastating disruptor of pharmaceutical systems, affecting everything from supply chains and local manufacturing to healthcare delivery and affordability7,8,9,10. 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 locally11,12. 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 destroyed13,14,15,16. 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 expensive14,15,17. The armed conflict has stopped local production, leaving less than 30% of manufacturers still in business, and made humanitarian supply corridors less reliable14,15,17,18,19,20,21,22. 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 illness1,2,8,23,24. 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. 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. 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).
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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
Fig. 1The alternative text for this image may have been generated using AI.
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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.
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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).
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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.

Fig. 2
Fig. 2The alternative text for this image may have been generated using AI.
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Medications shortages and availability among pharmacies.

Table 4 Frequency and proportion of drug presence and shortages (n = 118).
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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).
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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 access14,17,21.

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 population2,8.

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 resilience23,24,26. 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 populations12,17.

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 conflict15,17. Similar patterns have been reported in Ukraine and Syria, where chronic care patients were among the most affected by medicine interruptions1,23. Additionally, the conflict has contributed to secondary health crises16.

Disrupted vaccination campaigns have contributed to outbreaks of measles and other vaccine-preventable diseases21,22. 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 environments6,27,28, 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.