Disintegrated Somali health care system: From hapless to hopeless

Written by: Abdirahman A. Adam Dhere

Health sector is one of the most essential life sustaining principles in human life and devoid of it human being wouldn’t exist. A healthy individual shapes and delivers the outcome of a complete and a well-oriented society. As a result, better health is fundamental to human happiness and safety. It also makes an important contribution to economic progress, as healthy populations live longer, are more dynamic, and save more.

Numerous factors manipulate health status and country’s ability to provide valuable health services for its people. Ministries of health are significant actors, but so are other government sectors, donor associations, civil society groups and communities themselves.

As soon as the health is elementary need for all human species, beyond doubt the health sector in Somalia is still in a grave condition with one of the worst health indicators in the world. With a population of 12.3 million, 1.1 million people are internally displaced.

Acute humanitarian needs increase to some extent; the number of people current in need of humanitarian backing has reached 5 million, which is more than 40% of the population. The annual post-Gu assessment, which was released by the food and Agriculture Organization (FAO)-managed Food Security and Nutrition Unit (FSNAU) in September 2017

Somalia is among the least developed countries listed in the 2012 Human Development Index.  The country suffers from prolonged internal conflicts, poverty, human right violations, high population growth, desertification, recurrent droughts and famines, weak economy, poor governance, haphazard settlements, environmental humiliation and broken health care system.

After the fall of the central government, Somalia has been the archetype of a failed state in the world for the past 20 years. The Somali states slowly went to wrack and ruin over a period of a decade and then collapsed in 1991.

 

A malicious civil war and tyrant regime has overwhelmed the country since 1988 and the downfall of the political regulation has produced an indescribable tragedy by consuming nearly 700 000 lives and displacing over three million people. ‘‘United Nations, Humanitarian Situation in Somalia: Monthly Analysis, Nairobi, April 2007’’.

Somalia’s political blow has turned into the most terrible humanitarian crisis in the world; therefore these calamities have not only been limited to the despair of its people, and other than accompanied by the disintegration of public infrastructure and regulatory mechanism, such as recognized banking systems, telecommunications, provision of inputs, and access to international markets.

Political instability and poor governance has stifled the health care system, which suffering from scarce funding, misconduct, and overall poor planning and policy development ever since independence, and created an overwhelming of nation’s staggering health care system and its handling mechanism.

To make a correlation about past Somalia health care coordination and current misguided health care system, let us glance back a little bit; about the several highlights in the history of health care services in Somalia.

In early 1966, a nursing school was established in Hargeisa and another one in Mogadishu in1970.  Subsequently, in 1973, a faculty of medicine and Surgery was set up in Mogadishu.  In the 1980s, the commencement of these social institutions has brought in massive external assistance which is from international organizations and foreign governments.

It established primary health care training institutions and opened the door for medical specialty training in TB (tuberculosis) and lung diseases in late 1980s.

These training institutions boosted the human resources for health and literally expanded access to health care services and improved the quality of health care in Somalia at that time; particularly with regard to TB.

However, the substantial resources injected into the health care system were not used properly and their contributions faded soon. Another landmark of advancement was the formation of a semi-autonomous refugee health unit in the Ministry of health to serve the refugees from Ethiopia in 1977, which attracted gigantic foreign aid and expatriate health professionals.

 

The refugee health unit initiated brilliant health care planning and efficient operations which optimistically influenced the overall ministry of health functions and operations. The RHU staff gained precious experience and knowledge concerning civic health concepts and practices. These formed proficient public health professionals and raised the alertness and practice of public health in Somalia.

Also in 1980s, research in medical sciences was initiated by the faculty of medicine, in association with numerous universities in Sweden, through the National Academy of Science and Arts in Mogadishu.

This was a new crack of dawn in exploration in medical sciences and the other entire fields in Somalia. This initiative and others mentioned priory mainly contributed to healthy manpower production and smooth improvement.

Despite the training institutions, there were several parameters of controlli+ng contagious disease in Somalia, which has been fulfilled by foreign aid agencies. For instance, infectious diseases was the most abundant disease in Somalia, as quoted by the ‘‘New England journal of medicine 328 (1993): ‘‘the threat of infectious diseases in Somalia’’ after a while, the smallpox eradication campaign and introduction of Primary health care and new tuberculosis (TB) treatment regimens by the Finnish International Development Agency (FINIDA) was in progress in the mid-1970s.

The perpendicular programs that had disease-definite objectives were funded almost entirely by international organizations and development agencies, like UNICEF, WHO, UNFPA, FINIDA, USAID, UNDP, EU, and the SIDA.

In addition to that, WHO and UNICEF contributed many procedural plans; it funded a couple of primary health care line up that was experimental, whereas some of the other agencies were involved in program development, accomplishment, and assessment.

Also UNICEF was involved in the Expanded Program on Immunization operations, in collaboration with the WHO.

Likewise, FINIDA funded the national TB control program for at least six regions in Somalia, but quite certain change on the disease burden has been observed at that time, owing to poor proper usage. So far, Somalia’s health care system status illustrates the bottom of the list among the developing countries. (CIA, Somalia—World Fact Book, 2005)

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To be continued regarding the background of Somali health foundation and its international aid funding, there were multiple surveillances like, UNFPA (United Nations fund for population activities) ‘‘Somalia country paper’’ (2013) which was estimating the demographics and the social profile of Somalis, in order to plan the scheme of humanitarian services and operations; which was exceedingly vital for the sustainability of effective and accurate health care system.

Even though it was tough to find clear-cut reckon of the Somali population, nevertheless, at present, the population estimates quoted by these organizations range from seven to twelve million, with unsophisticated birth and death rates of 46 and 18 per 1,000 populations, respectively and an annual growth rate of 2.8% with a dependency ratio of 101%.

The total fertility rate is 7.3 babies per woman of reproductive age, underlining the significance of obstetric services and the risk of maternal deaths. The life expectancy at birth is 46 years for males and 49 years for females.

High mortality rates in the early stages of life are responsible for this poor life expectancy at birth. The infant and under-5 mortality rate estimates in 2000 were 130 per 1,000 live births and 224 per 1,000 live births.

Consequently, the long-drawn-out civil wars and disasters which have outraged the Somali population has aggravated these rates substantially and the overall crude mortality rates exceeded those recorded in neighboring Ethiopia and Sudan during the famine in 1984–85, seeing that in Centers for Disease Control ‘‘Population-Based Mortality Assessment’’ in Baidoa and Afgoye regions in South Somalia in 1992.

Beyond that, adequate resources, and the establishment of essential infrastructure is limited, concentrated in safe areas, chiefly in towns. There are currently 196 Mother Child Health (MCHs) clinics, 74 hospitals with 3,405 beds, 26 TB centers, 14 Out-patient departments (OPDs), and dispensaries, and 520 health posts, 13 mobile units, and 43 Malaria Microscopy centers.

These hospitals locate only in urban centers and regional capitals. In rural district restricted services are available, and medical facilities are not accessible.

Diagnostic facilities that are necessary to patient care are limited. In 2005, 114 clinical laboratories existed in the state.

From 2005 up to 2018, number of clinical laboratories, hospitals and diagnostic facilities has gotten worse, due to lack of investment and permanent maintenance.

Statistics on X-ray machines are not available, but each hospital was equipped with at least one, moreover those in TB hospitals. Some machines at region hospitals are not functional at the moment.

Consequently, sum X-ray machines in the country must number less than 74, although a few of those that had been out of order may have been replaced. WHO (Draft), “Health Facilities Overview, Somalia” (2005)

After the facilities, the disorders that were widespread early in the 1960s, after independence, have remained prevalent till today, health indicators advocated that there has been no improvement in the health of the population over the past three years.

Indeed, indicators show a slight increase in levels of infant and under-five mortality and pockets of chronic malnutrition persist in southern Somalia.

Several studies showed that Maternal Mortality Rate (MMR) is exceptionally as high as 1600/100 000. A baseline KABP survey on Reproductive Health and Family Planning in Somaliland was carried out by WHO Somalia in October 1999. The main findings include:

• Neonatal mortality rate (NMR), Infant mortality rate (IMR) and Child

Mortality rates (CMR), which are estimated to be 28,113 and 328 respectively

• Fertility rate of around 7.9
• 18% of married underage (<18) girls
• Female Gentile Mutilation Prevalence of 99%

 

But at this time the gifted hands of Dr. Edna Adam and her remarkable midwifery profession were due to the dramatic decrease of the Maternal Mortality Ratio.

She initiated the construction of Edna Adam Hospital in Hargeisa, Somaliland to train midwives, though the midwifery profession was one among those professions that has suffered the biggest attrition in terms of number.

Following that a momentary look about the list of the major health problems which are prevalent in Somalia:

• Sexually transmitted diseases including HIV/AIDS: The HIV/AIDS epidemic is a critical tackling in health care and development in Sub-Saharan Africa, where two-thirds of the world’s HIV/AIDS victims live (although they represent only 10% of the world’s population).

The HIV/AIDS prevalence in Somalia is around 1%. The prevalence of other sexually transmitted disease was as high as 30%. (Gillian Duffy, 199)

However there are factors that could propel the epidemic of the disease which mainly are; first, the cost of medical and social services for people living with HIV/AIDS is beyond the budget of the ministries of health in the majority of Sub- Saharan Africa;

Secondly, lack of knowledge and public awareness and devoid of using condemns for protected sex has exacerbated the disease.

HIV infected individuals inside Somalis usually faces intimidating Islamic Wahhabism and offensive cultural radicalism which may cause them phobia, irrational fear and drug discontinuation.

• Immunization coverage against the six childhood illnesses is very low: For instance, repeated outbreaks of measles in almost all the regions of the country is a good indicator of low immunization coverage, and the circumstances is more severe in the nomadic and rural areas.
• Water shortage is a common phenomenon in Somaliland, by the fact that the maximum annual rainfall ever recorded was 836mm in 1986 and the lowest was 156mm in 1965 (Hargeisa water agency, 1996). Availability of water in the urban settlements is also very low. It is estimated that the capital city of Hargeisa gets ¼ of its daily water requirements (ibid, 1996).

In this situation of scarce safe and clean water, it is no doubt that diarrheal diseases ranked number One among the endemic and epidemic communicable diseases, including Cholera and diarrhea.

• Lack of child spacing: No family planning and low percentage of breast feeding. Early marriage is another factor which also causes adverse effects on young mothers and their new-born, especially during delivery.

Female Genital Mutilation is further common crisis in the country which often results subsequent complications for young girls.

The most prevalent diseases that are responsible both the high morbidity and mortality rates are:

• Diarrheal diseases: Survey conducted in Somaliland in the 2000, 17% of children have had diarrhea two weeks prior to the survey. Under developed countries, children’s diarrheal diseases remain one of the leading lethal diseases.
• Tuberculosis
• Cholera
• Measles
• Malaria
• Acute respiratory tract infections (ARI): g.: Pneumonia

Subsequently, mental health problems increase as well. Oral health care also faces the same problem. Although mental and oral health professional Doctors are scarce, indeed both mental and oral health is neglected and at present the need is enormous and critical.

Beyond doubt, unsatisfactory outcomes of treatable diseases, such as tuberculosis, malaria, typhus, and dysentery, were mainly accredited to the poor quality of imported drugs, and lack of a strong regulatory body on drug importation and utilization.

The currently flourishing drugstores across the country are full of expired drugs which could seriously aggravate an already dreadful health situation.

However, despite the failure of the Somali central government and the stability degradation, further there are steady and stable areas with public administrations that fulfill some basic functions of governments.

For instance, Somaliland which is the northwestern part has declared its independence as the ‘‘Republic of Somaliland’’ it has broken away from the rest of Somalia since 1991 and have absolute positive development but lacks functioning civic infrastructure and the deficiency of  entire nation’s strategies, which were never based on precise facts and figures, even though failed to offer apparent guidance to the frontline decision-makers about the overall health care mission and the motivating principles of health care service delivery.

Somaliland constitutes of six main cities, chiefly the capital city of the Hargeisa, Borama, Erigavo, Burao, and Lasanod, these regions which is where I was born and grown up as a mature have a very high security profile as well achieved outstanding governmental system framework.

In neither spite of the effective nor the ineffectual governmental system in Somaliland for about the last two decades, still Somaliland undergoes overall fallible and fragile civic infrastructures. Specifically the health sector suffers mostly due to various flaws particularly due to inadequate funds for health service operations; Poor health development planning; Poor quality of available health care services and deprivation of advanced health care facilities.

A clear sign which can illustrate the poor health care services in Somaliland is the severe scarcity of suitable diagnostic equipments and imperfect misuse of the investigative tools by a few unprofessional health care staffs.

A clear indication can be the country’s chief city Hospital Group, Hargeisa, this hospital which is the largest and the oldest hospital across Somaliland. There are various serious calamities which has ruined the overall health care service in Hargeisa. Devoid of diagnostic tools, dreadful health care service, limitation of manpower, medical supplies, drugs and funds are the misfortunes included.

The health care service status in Hargeisa has no progress at all for the last 25years. Somaliland health care service status shows overwhelming circumstance. For instance, a significant portion of diagnostic equipments are absent from the main hospital.

Current 2018 Hargeisa Hospital diagnostic facilities are insufficient. There is One Chest X-ray, One Ultra-sound, One CT scan with foreign Syrian radiologist, and One Anaesthelogist. Besides unfortunately there is no MRI (Magnetic Resonance Image) through the entire hospital.

It’s an embarrassment that the major hospital in the city have this kind of shortage of facilities.

In addition, the late civil wars, droughts, and the misguided national health policy wiped out the gains in health man-power production and development.

Though lots of expatriate health professionals whom am included graduates each year from the neighboring great Ethiopia and rest of the world which had literally raised the awareness and the quality of health care services. Nevertheless there is no accomplishment of national health development plans and strategic policy to ensure efficiency in the delivery of health care services and to make the system operational and sustainable.

 

Abdirahman A. Adam Dhere is Academic Researcher; Writer and Social Activist. He is Also a Horn of Africa Analyst.

Based on, Addis-Ababa, Ethiopia

Contact me:

Twitter: @AdamDhere4264

     Email: Biyo 21069@gmail.com

Face book account: Abdirahman-Biyo Kama dhibcaan

 

 

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