Supply Chain Determinants of Treatment Interruption and Mortality in Haemodialysis Centres: A Comprehensive Analysis of Sudan's Largest State

Background: Northern State, the largest state in Sudan by area (348,765 km²), hosts the country's second-largest haemodialysis population (919 patients), creating unique logistical challenges for renal care delivery. This study examines the relationship between supply chain reliability, equipment maintenance, and clinical outcomes across all haemodialysis centres in this vast, remote region. Methods: We conducted a complete census of all 13 haemodialysis centres in Northern State, Sudan between October and December 2025. Using structured instruments, we collected comprehensive data on equipment functionality, supply availability, maintenance practices, and clinical outcomes. We computed two validated indices: Essential Availability Index (EAI) and Medication Availability Index (MAI). Statistical analyses included descriptive statistics and Pearson correlations. Results: The 13 centres served 919 patients (341 female, 578 male) across this vast territory. We identified critical supply chain fragmentation: essential supplies showed consistent availability (median EAI: 2.9, IQR: 2.8-3.0) while medications faced severe shortages (median MAI: 1.5, IQR: 1.1-1.9). MAI demonstrated a strong inverse correlation with mortality rates (r = -0.63, p=0.021), whereas EAI showed only weak association (r = -0.32, p=0.286). Machine downtime strongly predicted treatment interruptions (r = 0.72, p=0.006). Geographical remoteness disproportionately affected medication availability (r = -0.58, p=0.039). Only 46% of centres performed monthly preventive maintenance, with these centres demonstrating 59% lower machine downtime ratios than centres with no maintenance (0.09 vs 0.22). Conclusions: In Sudan's largest state, medication supply chain failures rather than essential supply shortages are the primary supply-side determinant of patient mortality. The vast geographical expanse exacerbates these challenges. Urgent interventions should prioritize reliable medication supply, standardized maintenance protocols, and geographically-equitable distribution to improve haemodialysis outcomes in this vulnerable population.