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Beyond the pandemic: strengthening Somalia’s health system

Written by Sorcha O'Callaghan, Fawziya Abkiar Nur, Amy Kesterton, Peter de Clercq

Covid-19 has laid bare the fragility of Somalia’s health system. Decades of conflict, poverty-related deprivation and limited state capacity has meant that Somalia is one of the countries least capable of managing this mutually overlapping catastrophe.

Primarily delivered through a poorly regulated and uncoordinated network of humanitarians and the private sector, the health sector grapples with chronic shortfalls in capacity, infrastructure and medical personnel. The result is a healthcare system ill-equipped to manage the health needs of the majority of the population in normal times, let alone a global pandemic.

Most funding for the health sector comes from international donors and is ‘off-budget’. This means it is channeled directly to healthcare providers through a patchwork of projects and instruments, rather than through government systems and budgets. Although bypassing Somali systems is unsustainable and diminishes government accountability over the longer-term, this has been a pragmatic response to poor levels of donor confidence in weak government financial systems.

But there are grounds for optimism. Earlier this year, the Federal Government of Somalia (FGS) cleared its arrears to the International Development Association. This allows Somalia to access new resources and paves the way for debt relief. The World Bank and other health donors are gearing up for new projects and funding. There is widespread recognition that the current reliance on humanitarian funding and delivery is insufficient. The time is right to work towards a unified vision for the Somali health system.

In September, FGS’ Office of the Prime Minister and ODI’s Humanitarian Policy Group brought together 31 Somali and international actors to explore how Somalia can build a sustainable health system. Three leading experts give their views here.

— Sorcha O’Callaghan, Director of the Humanitarian Policy Group, ODI

Frequently asked questions

Fawziya Abkiar Nur: the view from the Federal Government of Somalia

Recurring humanitarian and health emergencies in Somalia have mobilised international and local partners to deliver health services to Somalis. Despite these efforts, health outcomes in the country are unacceptable. Amid the Covid-19 pandemic, the health of vulnerable populations and Somalis at large is at stake.

The nation needs to build a resilient health system that is affordable, consistent and equitable. This is the bedrock upon which national health can be improved and future adversities overcome.

Priorities for the Somali health sector

The Somali government is working to define and implement a deliberate and inclusive strategy and create sustainable, consistent and equitable healthcare. To rise to this challenge, we are focused on delivering a package of essential health services, building human resources through national training institutions, while strengthening the Ministry of Health’s institutional capabilities.

How is the government leading the reform?

The government is responsible for supporting all of its partners to deliver health services in a coherent manner, with the Ministry of Health (MoH) coordinating humanitarian, donor and private partners to this end.

The National Development Plan (PDF), the newly developed Essential Package of Health Services (EPHS) and the forthcoming flagship Damal Caafimaad project (in January 2021) all seek to align the current patchwork of sector plans and proposals across the country. This will address inconsistencies in health sector salary support and donor approaches, and foster consensus on policy and implementation.

The EPHS – a major new scheme to provide a comprehensive range of free health services across nine regions of Somalia – will enable international and private partners to contribute to extending healthcare that is suited to our needs, while building trust with beneficiaries through improved healthcare standards.

Damal Caafimaad is a new health project being developed with the World Bank for an estimated $100 million which will deliver on two fronts. Firstly, it will ensure that country systems are used and prioritised as part of the EPHS. Secondly, it will strengthen Somali public finance and procurement systems to enable better on-budget health financing to government institutions.

Furthermore, the MoH’s ongoing work with the medical, nursing and midwifery schools will ensure we have qualified medical professionals, to secure the future quality healthcare of the country.

I call upon all partners to join this journey and align their technical and financial support with the Somali National Development Plan, as well with the health sector polices and plans to strengthen Somalia’s health systems. We hope these will emerge stronger than ever from the Covid-19 pandemic.

Frequently asked questions

Amy Kesterton: the role of international donors

The recent Somali Health and Demographic Survey paints a sober picture. Only 11% of children receive the basic vaccinations needed to protect them from common childhood illnesses such as measles and polio, for which the world has long had the technical solutions to defeat. Just a third of children are born with the services of a skilled midwife, nurse or doctor and one in twenty women aged fifteen today will die of pregnancy and birth related complications.

With this backdrop, the vision for the Somali health sector is clear. The focus must be on reducing the unacceptably high rates of preventable death and illness. All available resources must be used effectively, efficiently and equitably to get the many existing basic, cost-effective health interventions to those that need them.

International donors have an important role to play in helping deliver this vision. They must advocate for domestic resourcing and commitment to health, and work to build government capacity to lead the health sector. They must better coordinate their resources to maximise impact and support a shared approach to delivering on the vision. 

In Somalia this requires working with the government to extend a core package of services focused on the highest burden of ill health. It requires helping design and implement appropriate financing, human resources and other strategies to gradually strengthen the health system. 

In a fragile context such as Somalia, donors also have a responsibility to help align everyone towards the same vision. They must bring the humanitarian and development communities together and ensure the strengths of the private, non-governmental, community and faith-based organisations are all harnessed.

Frequently asked questions

Peter De Clercq: the view from a former UN Humanitarian Coordinator

With the exception of life-threatening emergencies, humanitarian funding for protracted crises may well become more constrained, especially in the aftermath of Covid-19. Rather than accepting the reality of annual $1 billion humanitarian appeals for Somalia, largely off-budget and driven by external stakeholders, we therefore need to redefine “humanitarian” activities in key sectors such as health as transitional, governance-based interventions.

A continuation of the humanitarian reflex in Somalia undermines the pursuit of national ownership, even if the purpose, content and outcome of such programmes may be correct and beneficial. We should continue to make “business cases” for the prevention of predictable health crises in Somalia, instead of mounting repetitive and reactive operations post-facto.

This means supporting government-led investment programmes that enhance structural and community resilience to external health challenges, such as the one we are facing now.

The Somali government should reinforce its grip on the management of health activities and structures, using the Somali Development and Reconstruction Facility (PDF) – the agreed aid architecture for the Somali National Development Plan – as a coordination platform.

The “on budget” approach is a first step in the right direction in this regard.

At the same time, enhanced Somali ownership does not require the immediate implementation of all ongoing health programmes by the Ministry of Health (MoH). Instead it means the MoH manages and oversees the outsourcing of external non-governmental activities, with a clear and timed exit clause. This is moreover an opportunity for decentralised government ownership and a stronger role for state structures closer to their constituencies.

To reinforce a government role in the health sector, we could think about co-signed agreements between the MoH and implementing entities, or through public-private partnerships.

Under such arrangements, the MoH would be part of the relationship between donors and implementing partners, which would promote a more structured and standardised approach. The substantive role of external actors should not be fought at this point, but instead regulated and subjected to clear government standards.