WHO Country Program Statement 2000-2001: Somalia

COUNTRY SITUATION
As a summary statement, the status of the population's health and the health system in Somalia is very poor with periodic limited short life span improvements. The trend is downward with a few area based and disease specific exceptions. Cholera is now an annual phenomena with seasonal peaks. Exacerbated by the floods in the South, malaria continues to be a major killer. Health care for many is only available from drug vendors or traditional healers. Mental health is a growing concern.

On the positive side, the private health care sector is booming but the commensurate concerns related to their quality and safety are increasing. Security remains a fluctuating phenomena in most parts of Somalia. Attempts at reconciliation continue with scattered and short duration success. With the primary purpose of fostering peace, fledgling local or area based administrative structures are being re-established with donor support. However these scattered local administrative structures are yet to direct resources to health systems development.

Prior to the 1990 civil strife, Somalia stated that it was committed to attain the goal of health for all by the year 2000 through primary health care. Development plans were drawn to initiate basic health services focusing on rural and nomadic populations. The planned health care delivery system then consisted of 411 health post, 94 maternal and child health centers, 50 primary health care units, 52 district hospitals, 19 regional hospitals, 4 general hospitals and 17 specialized hospitals. These facilities had been approved by the Government but with sometimes complete dependence upon support from the donor or NGO community. A large percentage of these then planned facilities were either not functional or operated at a basic level due to the governments redirection of financial resources and the emerging security related problems. Additionally, due to both the convenience of donor funding and priorities of the then existing administration, the distribution and mix of health care facilities and programs did not follow population distribution patterns. Substantive health care was only available in the large urban centers.

The disaster that followed the civil war has for more than eight years seriously affected the health status and health services available to the resident population. A 1993 WHO survey found 95% of the pre-war functioning health services facilities either seriously damaged and/or completely looted. Additionally, there was a massive migration of trained health personnel, either to other countries or to secure areas within Somalia specific for their clan affiliation. The very limited pre-war water supply systems and sanitary facilities were destroyed. Food production and distribution systems were seriously constrained resulting in massive levels of malnutrition and deaths in most of Somalia.

Starting in 1992, UNITAF and then UNOSOM made possible a massive influx of assistance to Somalia. This assistance with 200 plus international NGOs physically present along with the enhanced presence of UN Agencies did help to assure the survival of many in Somalia through the provision of food, essential drugs and health services. Immunization levels reached what is considered all time high levels in many parts of the country due to the availability of a massive logistical support system along with very high donor funding. Large numbers of MCH centers, OPDs and hospitals were either rehabilitated or reestablished to serve the urban, rural and internally displaced populations.

Subsequent to the departure of UNOSOM from Somalia, the number of operational NGOs in Somalia dwindled to less than thirty but has rebounded to around 40 at this time. The operational sites and resources available to UN Agencies and NGOs has been proportionally reduced. Essentially all of the remaining NGOs and UN Agencies working in Somalia now have serious security and logistical related limitations on their activities with the partial exception of the North West.

The incidence and prevalence of communicable diseases, especially malaria, tuberculosis, and cholera remain high with sexually-transmitted diseases continuing to increase. The often untenable security situation in many zones adds to the problem, rendering the delivery of health care services difficult or impossible. Administrative authority is virtually absent at all levels in most of the country with the result that the formal health sector continues to be entirely dependent upon external assistance. Through the direct assistance of international NGOs, donors and WHO, some hospitals remain functional. However, most of the prewar hospitals have remained a shell, were looted during the war or were subsequently re-looted. A similar situation exist for MCH centers and OPDs in most parts of the country. The number of health post are however thought to nearly equal the pre-war planned level and to actually offer a higher level of service than prewar due to their actual receipt of essential drugs.

Somalia has made a smooth transition from a country with an inadequate supply of qualified health manpower to a country with only token numbers of qualified health professionals. In the eight year absence of new qualified health professionals in Somalia and with the continued exodus of many, Somalia is facing a bleak health care future.

Over the past eight years, six areas of Somalia have established fledgling health system administrative structures within the context of a local government. Only one of these structures remains effective. However this remaining structure does provide an opportunity for Somali professionals, NGOs, UN Agencies and the donor community to reestablish health structures and systems with hope for at least partial sustainability.

Safe water and basic hygiene are uncommon.

Illiteracy is the norm and with literacy soon to be the rare exception.

Health system information sharing and collaborative coordination is now a developing reality for Somalia. Although UN Agency, NGO and donor driven, essentially all elements of health systems development are discussed in monthly meetings with the concerned parties. Operational standards, guidelines and strategies are openly discussed and promoted for use by all in Somalia. Although welcomed, the participation of Somali health professionals in these meetings is constrained by the continuing logistical problems.

Pre-civil war data collected and reported for Somalia remains, for the most part, the only defensible data for planning and evaluation purposes. This prewar data is augmented below as indicated to accommodate more recent developments in Somalia and the continuing conflicts in various zones. The past and present situation in many parts of Somalia still does not permit capture of reliable data. Hence, most of the data in the following table is either 'fuzzy' or outdated. Current demographic and health systems data are reflected in Table 1.

Main achievements and Constraints

Achievements and failures

Recent achievements include a semi-formal health systems coordination, planning and development process for Somalia. This development represents a significant improvement over both the pre-war and immediate post-war process when it was essentially non- existent Now, donors, NGOs and UN Agencies meet monthly to share developments and security concerns. Through a task force process health systems development elements are coordinated and focused. WHO serves as Chairman of the Essential Drugs, Training, Health Information Systems, TB and Cholera tasks forces and actively participates in others. Efforts are now underway to extend this coordination and cooperation process to the regional or zonal level in Somalia.

During the recently completed biennium, WHO was able to significantly increase its health manpower development efforts. Although still limited to selected fellowships and short term training, the volume of short term training is now an order of magnitude higher that the previous biennium As a natural response to the health manpower situation in Somalia, an agreement has been reached among UNFPA, UNICEF and WHO to jointly support Midwifery Training Institutes during the current biennium

Although routine immunization activities in Somalia continue to be unacceptable, with UNICEF provided vaccines, WHO was successful in implementing Sub-National Immunization Days for Polio eradication in both North East and North West Somalia.

Given the near predictability of cholera and malaria in Somalia, WHO was successful in arranging for the early least logistical cost distribution of needed supplies and essential drugs.

Under the circumstances in Somalia, the above limited achievements and others can be attributed to the good work of some of the very committed Somali health workers, the dedicated staff of international NGOs and UN Agencies and the kindness of the donor community. The failures that can be inferred from Table 1 can be attributed to the continuing insecurity, corruption, and very high logistical and administrative cost of operations in Somalia. The until recent absence of a fully implemented coordination mechanism for donor and UN assistance has also led to some duplication and reduced effectiveness.

Specific failures include: a still unimplemented epidemiological surveillance system; the re-direction for security reasons of essential drugs intended for the Mogadishu area to the Northern parts of Somalia; the continued security related constraint on leprosy treatment, our failure to convince donors to increase support to the NGO operated TB treatment centers and, perhaps most importantly, our failure in promoting peace and reconciliation.

Constraints

The availability and high cost of logistics is second after security as a constraint on the work of all donor, NGO and UN Agencies in Somalia.

With few notable exceptions, essentially all of the gains obtained during the resource intensive assistance period of UNOSOM have been lost due to insecurity, the withdrawal of international NGOs, logistical constraints and perhaps most importantly due to the non-sustainable nature of the established programs and projects. As both a development and humanitarian agency, WHO must work to better focus the limited available resources for Somalia to the development of sustainable health systems that meet the basic health needs of the population.

Objectives, targets, products and projections

2.3 NATIONAL HEALTH POLICIES AND PROGRAMME DEVELOPMENT AND MANAGEMENT

Strategic Objective: Local authorities and community leaders to assume more responsibility for health systems development and management in their areas.

WHO Targets: All zones or regions with an established recognized local authority will have agreed to a more sustainable methodology for the achievement of health for all through primary health care recognizing their full partnership and responsibility for the inputs required for health systems development and maintenance.

New and existing district level authorities will be provided with reference material and guidance on the development and implementation of District Health Systems.

A communications and logistical support structure will exist for WHO to provide support to Somali health professionals and developing institutions with six sub-offices in Somalia

2.4 BIOMEDICAL AND HEALTH INFORMATION AND TRENDS

Strategic Objective: Assure the availability of a common up-to-date data base with demographic and epidemiological details, working health facilities and available health manpower for use by all in planning, monitoring and evaluation.

WHO Targets: All Districts with a recognized authority will have a functioning basic health information collection, analysis and reporting system with or without NGO or UN Agency Support.

The district level health systems data base assembled by WHO and UNDOS will be made available to all interested international and Somali professionals.

Coordination and cooperation with the GIS section of UNDOS will continue and result in additional health coverage, EPI and health resource maps for use in planning and evaluation of health system resource decisions.

3.1 ORGANIZATION AND MANAGEMENT OF HEALTH SYSTEMS BASED UPON PRIMARY HEALTH CARE

Strategic Objective: Through an intersectorial approach, empower local authorities, communities and villages to establish and maintain their own health systems to meet their own basic health needs.

WHO Targets: A cumulative total of at lease 100 villages will have received formal training and assistance in the implementation of sustainable Basic Development Needs/Quality of Life program with two new model villages established outside of existing BMN areas. (Locations to be determined based upon security and logistical considerations.)

Fifteen operational district health structures, if in existence at that time, will be provided training and technical assistance for the development of an integrated district health care system with a good referral system at the secondary and tertiary care levels. (The locations of such districts is dependent upon the then existing security situation, the availability of District Level Authorities and resource commitments from the respective communities.)

3.2 HUMAN RESOURCES FOR HEALTH

Strategic Objective: Reinforce the professional skills of the remaining health professionals and establish a mechanism for the production of new health professionals for work in Somalia.

WHO Targets: Establish and train four regional level health teams in district based problem solving techniques, nutrition assessment in emergencies, epidemiological surveillance and response to disease outbreaks.

Provide monthly health literature updates to 150 Somali Health Professionals that are tailored to their professional field and skills.

Conduct training sessions for 100 working Somali health professionals each in the control and treatment of malaria, ARI and diarrhoeal diseases.

Provide hands on training to the staff of 10 NGO or health authority supported laboratories for one week each.

Provide hand on refresher training to the laboratory staff of each of the functioning TB treatment activities.

Provide training on the rational use of drugs to 100 health workers and 100 pharmacist in both the NGO/UN Agency supported and private sector.

Reopen Hargeisa Health Training Institute, Post Basic Training Institute in Mogadishu and a midwifery training institute in Merca.

3.3 ESSENTIAL DRUGS

Strategic Objective: Promote the availability of basic life saving drugs and essential drugs system through the private sector and provide TB and Leprosy drugs to properly functioning centers.

WHO Targets: Make available at the district level essential drugs for the treatment of malaria and diarrhoeal diseases.

Make available to properly functioning TB and leprosy treatment activities all needed drugs, reagents and supplies.

Training in the rational use of drugs, proper storage, distribution and professional development for private pharmacist and drug importers.

3.4 QUALITY OF CARE AND HEALTH TECHNOLOGY

Strategic Objective: Improve the quality and accessibility of reliable laboratory services

WHO Targets: Four WHO monitored reference laboratories providing higher level referral support including the provision of cholera diagnosis will be supported. (One directly and three in coordination with NGOs and area health authorities).

Ten area health authority or NGO operated laboratories will have needed training, monitoring and supervision including safe blood practices.

One hundred private and supported laboratory workers will receive one week of hands on refresher training.

Quality assurance test on publicly sold TB drugs and antibiotics.

4.1 REPRODUCTIVE, FAMILY AND COMMUNITY HEALTH AND PROMOTION

Strategic Objective: Reduce maternal mortality.

WHO Targets: In cooperation with UNFPA and the Health Authorities in Hargeisa, technical and material support will be provided for the training of 60 midwifes through a two year course of work at the Hargeisa Health Training Institute and at the WHO/Caritas facility in Merka. (30 per year)

On the job training for two weeks will be provide to the staff of 40 MCH centers through the employment of a UNV/Nurse Midwife educator.

Condoms will be provided to any MCH center or health facility that so request and receives training in the diagnosis and treatment of sexually transmitted diseases.

Two thousand copies of the Somali version of WHO's abstract of religious tenants on female genital mutilation will be distributed to religious leaders, community leaders and women's groups in Somalia

4.2 HEALTHY BEHAVIOR AND MENTAL HEALTH

Strategic Objective: Increase the capacity of the informal and formal health sector to assist those with mental health problems.

WHO Targets: In cooperation with UNESCO, a booklet in Somali language will be developed and printed for use by teachers and health workers on methodologies for providing assistance to the mental health of the population and individuals.

A WHO expert will examine the existing mental health problems in Somalia and propose implementable mechanisms for informal assistance.

4.3 NUTRITION, FOOD SECURITY AND SAFETY

Strategic Objective: Increase awareness of the cross linkages between nutrition and health.

WHO Targets: Twenty additional Somali professionals will be trained in Nutrition Assessment Methods in Emergencies.

A FAO/WHO jointly funded consultancy will examine the food productions patterns in Somalia and recommend the introduction of new crops for production as a cash crop and for local consumption.

4.4 ENVIRONMENTAL HEALTH

Strategic Objective: Foster a standardized sustainable approach to water and sanitation efforts in Somalia.

WHO Targets: Find a commercial use for the plastic bags which litter the country side in Somalia. (These khat bags are blow by the wind and decorate trees and bushes all over Somalia serving as a water collection point for mosquito breeding as well as being unsightly.)

Provide technical guidelines and reference material to all NGOs and area authorities working in water and sanitation.

5.1 ERADICATION/ELIMINATION OF SPECIFIC COMMUNICABLE DISEASES

Strategic Objective: Reduce morbidity and mortality associated with preventable diseases.

WHO Targets: Increase coverage of all six EPI antigens to at least 70% by 2001.

Conduct at least two supplementary immunization activities reaching at least 90% of children less than five years of age by 2001.

Assure adequate AFP surveillance to permit certification of the eradication of poliomyelitis.

Provide all necessary support for the treatment of 1000 leprosy patients.

5.2 CONTROL OF OTHER COMMUNICABLE DISEASES

Strategic Objective: Reduce the incidence of TB and better monitor other emerging diseases.

WHO Targets: Support international NGOs and functioning area health authorities in the use of DOTS.

Leverage AFP surveillance to increase the coverage and effectiveness of routine epidemiological surveillance.

Monitor chloroquine resistance.

5.3 CONTROL OF NON-COMMUNICABLE DISEASES

Strategic Objective: Increase awareness of oral health and the dangers of tobacco products.

WHO Targets: Make tobacco products the most heavily taxes item in a newly re-established Somali government with at least part of the resulting revenue directed to the heath sector.

Increase the number of dentist working in Somalia form zero to one.