The Role of Health Care in State-Building for Somalia
By Mahamoud A. Jimale
“If you think about how healthcare is delivered, it’s on ad hoc basis. Someone comes into a hospital, someone comes into a pharmacy, and someone comes into a doctor. But beyond those touchpoints, the patients are on their own. There is no real continuity of care.” – Christopher A. Viehbacher, CEO, Sanofi
Somalia is a very poor country and the per capita income is one of the lowest in the world. The people have been trapped in the midst of protracted civil strife and chaos which has inevitably threatened to overwhelm the already precarious health care condition. Over the last two decades the ongoing civil war has destroyed all of the health-care and economic infrastructures in the country. Many community clinics and hospitals established by the government were completely shattered and pillaged. As a result of the widespread food shortage crises, many people moved from the countryside into cities and towns. There was a mass exodus of people fleeing especially from the countryside due to famine to Mogadishu which had a pitiable impact on health and sanitation.
Most troubling, Somali healthcare underperforms relative to other countries. Our infant and child mortality rates are among the highest in the world even among the post conflict African countries. There are many causes: lack of adequate immunization, poor sanitation, malnutrition, diarrhea, acute respiratory diseases, malaria, etc. Consequently, the federal government through the Ministry of health (MOH) speedily fostered mother and child care (MCH) centers with free of charge healthcare especially for nutrition supplements and immunizations. Despite these little improvements undernutrition is still the cause of death of one-third of children under five years of age. Acute treatment such as oral rehydration for diarrhea and case management with antibiotics for acute respiratory disease is inadequate across the country. In fact, we are still suffering from the human tragedy effects caused by the civil war.
Chronologically speaking, at the summit of the conflict, different factions controlled different swaths of territory of the country. By its multiplicity, there were really many distinctions and healthcare shortfalls among individual factions, and as a consequence, our healthcare system continued to function minimally but the quality of the healthcare was much worse than before the war. The combined efforts of the Internal Committee of Red Cross (ICRC) which has spent one-third of its annual budget in 1992 on humanitarian assistance in Somalia, the Somali Red Crescent, the MSF, Save the Children, UNDP, etc. made it possible to negotiate some emergency healthcare in their fiefdoms.
Over the past 2 decades civil strife also caused a critical shortage of healthcare workers which has exacerbated the significant brain drain of physicians and nurses from our country. A rough estimation is that nearly two-thirds of the healthcare professionals mostly trained in Somalia (with the assistance of government educational subsidies) immigrated and are currently living in the diaspora. In effect, refugee physicians constitute 27% of the total doctors working in the United States and 33% in the United Kingdom. I hope that some of these people will return home now that stability in the country is improving by the day.
The rapidly changing social, economic and political environment in Somalia is creating conditions and opportunities to reconstruct and develop the Somali healthcare system. Yet, despite these gains, we are struggling to advance a sustainable strategy to rehabilitate and manage our health care problems. Similarly, current trends in demography, epidemiology, and delivery of healthcare suggest that the Somali Ministry of Health should be able to put in place a modern permanent new healthcare plan that can respond to the healthcare needs of the entire country.
Also, the Somali Ministry of Health must put in place a plan to advance the reconstruction and restructuring of existing referral, regional, district and community clinics which were devastated by the civil war and build new regional and district hospitals and community clinics. As a result of the ongoing civil war, there was a heavy emphasis on acute medical care and less attention was paid to preventive care or chronic management. Principally, the healthcare delivery systems were based chiefly on a primary healthcare model with integrated service delivery at the local level. The country was divided into 18 regions. The government through the Ministry of Health (MOH) was the principal healthcare provider.
The MOH was responsible for the nation’s health, including policies, goals and strategies for health development and delivery. The district authorities were responsible for delivery of primary healthcare services through minor clinics or health posts which served remote and rural areas, clinics, or district hospitals. Further, the central government provides referral hospitals at Mogadishu General Hospital “Degfer” (currently called Recep Tyyip Erdogan Research and Referral Hospital), Benadir Women and Children’s Hos., Medina and Forlanini Hospitals, and the rest at regional hospitals for example, Hargeisa Regional Hos., Kismayo Reg. Hospital, Gal kacyo Reg. Hospital, Belet WeynReg. Hospital Garowe Reg. Hos., Baidoa Regional Hospital, etc. Hospital care, medications and laboratory tests were free for all citizens in government facilities. The most significant partners with MOH were the Faculty of Medicine and Surgery of the Somali National University and the Poly ambulatory of Cassa per L’assicurazione healthcare facilities in Mogadishu, Somalia. The Faculty of Medicine and Surgery of the Somali National University trained its medical students mostly at the above mentioned hospitals.
Given the shortage and inadequate distribution of healthcare workers in Somalia, training more physicians, nurses, social workers, and other health care providers (e.g. physician assistants and nurse practitioners, etc.) should a priority policy issue in national healthcare. What is needed now and in the future is to open and revive the existent medical faculties in harmony with twenty-first century medical education. Attention must be focused on the rapid advancement in biomedical science which will have a great impact on the basic structure of the various faculties of medicine curriculum around the country. These faculties of medicine as well as MOH need the federal government to invest funds along with international financing and other donors.
Lastly, Somalia can tap into the resources of the thousands of Somalis living in the diaspora by providing them improved access to acute medical services as wells as managing needed care for their chronic ailments during their sojourn in their home country. Given the absence of a modern Somali health care system we can learn from the innovations that have been employed in other countries in terms of preparing their primary care physicians, medical practices and their overall health care systems. Somalia needs to build model hospitals and health systems which would include continuing care for pregnant women, newborns, child health services, water sanitation, HIV and other infectious disease control. The payment systems should include travel medical insurance with coverage for hospital care, surgery, office visits, prescription drugs and medical evacuation when the need arises. Somalia appears likely to take significant strides in order to develop a health system suitable for our country in the coming years.