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Somalia: Somalia Health Profile 2012






Solomon Islands Health Profile 2012

There is no consolidated estimate of the resources allocated to health care provision in Somalia from public and private sources. Given prevailing political and security uncertainties, available assessments of macroeconomic perspectives are cautious and vague. However, most analyses reach the conclusion that Somalia will remain poor for
long, even with peace and stability. It could even get poorer, if the flow of diaspora remittances dries out, as anticipated by some observers. There are, however, indications that in some regions public funding is increasing substantially: in Somaliland, for example, funding for the MoH has grown from 1,607 million Somali Shillings in 2000 to a budgeted total of 4,573 million for 2004, with a proportion of the total health budget growing from 2.3% to 3.2% for the same period. In Puntland, spending on health doubled as a percentage of overall spending, albeit to a still low level of 1.8% in 2004, which was the pre-war level. Total expenditures amount to around 4,754 million Somali Shillings (WB, 2005).
Private financing is considered important by all informants, and its growing role is reflected by the flourishing private sector, whose expansion can be seen also as an encouraging sign of trust and stability. Given large income disparities between rural and nomadic communities, and recipients or not of remittances from abroad, private contributions (and consequently access to paid-for health care) are likely to be very uneven. Better-off patients rely frequently on health services provided in foreign countries.
It is impossible to quantify private spending. According to the UN Transition Plan for 2005, private spending might represent up to 80% of all health financing. The WHO Statistical Information System puts private expenditure at 55% of total expenditure on health in 2001. Both estimates are mere guesses. Given the prevailing widespread poverty, it seems reasonable to assume that remittances from the diaspora represent an important source for private health expenditure. Somalis living abroad have also financed investments in health facilities, some of which are offering high-tech services. Local businesses represent an additional not quantified source of private financing. The total resource envelope allocated to health care in Somalia is likely to remain tight, in the order of US$ 8-10 per head, if the political and security situation remains dire. With improving conditions, donor increased support and a better economic performance may lead to funding levels of US$ 12-15 per head. In any case, no reconstruction bonanza is to be anticipated. The future health sector must be designed with this tight resource constraint firmly in mind. Given the small size of the health sector, regional partition, and weak or absent governance, operational fragmentation, general under-resourcing, lack of public budget systems and of banks, the absorption of the expanded financial allocations spurred by peace and recovery is likely to be poor. Poor systemic absorption is made worse by the tiedness of much financing, controlled by projects, vertical programs and private donors and operators. No fungible funds are available to fill gaps, remove bottlenecks and invest in sector-wide systems.

Trends in financing sources:
Financial, as well as human, resources are inadequate, and Somalia depends almost entirely on external sources for health financing. In 1989, the Ministry of Health was allocated 2.95% of the government’s regular budget. While 67% of the total health budget came from external aid in 1984, 95% of the utilized budget came from this source during 1990. In 1990, over 79% of the Ministry of Health’s financial resources were allocated to Mogadishu, the capital, alone. Many health programs suffered serious setbacks due to lack of funds and rising costs. The implementation rate of health projects was as low as 35.3%. Prior to the war, the provision of public health services was heavily subsidized by foreign aid. In 1989, over 95% of the Ministry of Health’s budget was funded by donors, with the government allocating only 2% of its recurrent budget to health. An urban bias and uneven access to health services, poor quality of care due to inadequate training of health care providers, mismanagement and poor knowledge and practice, contributed to generally poor health indicators. Foreign aid continues to  subsidize public health services. The Somaliland and Puntland administrations currently allocate some public money to the health sector. In 2000, however, this amounted to as little as 2.9% and 2.5% respectively of Somaliland's and Puntland’s recurrent budgets, and was mostly allocated to salaries. Over the past decade, however, private health provision has grown significantly. In 1997, for example, it was estimated that 90% of all curative care was being provided by the private sector, with up to 75% of the population in some areas utilizing private health facilities. This trend is encouraged by declining external finances, a lack of resources or commitment by administrations to support a public health service, and a lack of qualified personnel. In this context, community self-financing of minimal services is considered the only option for sustaining health services.

Brief History of the Health Care System
Until the collapse of the national government in 1991, the organization and  administration of health services were the responsibility of the Ministry of Health, although regional medical officers had some authority. The Siad Barre regime had ended private medical practice in 1972, but in the late 1980s private practice returned as Somalis became dissatisfied with the quality of government health care. From 1973 to 1978, there was a substantial increase in the number of physicians, and a far greater proportion of them were Somalis. Of 198 physicians in 1978, a total of 118 were Somalis, whereas only 37 of 96 had been Somalis in 1973. In the 1970s, an effort was made to increase the number of other health personnel and to foster the construction of health facilities. To that end, two nursing schools  opened and several other health-related educational programs were instituted. Of equal importance was the countrywide distribution of medical personnel and facilities. In the early 1970s, most personnel and facilities were concentrated in Mogadishu and a few other towns. The situation had improved somewhat by the late 1970s, but the distribution of health care remained unsatisfactory. The Somali health system was already in disarray at the time of Siad Barre, with wide inequalities in access to health services between Mogadishu and the rest of the country. According to the policy adopted at the time, health and education were free of charge. The capacity of transforming policies into action was, however, limited, and so were the resources, largely provided by the international assistance (94% of the health budget in 1989). As a result, an indigenous, coherent health system never took off. No sector-wide adoption of the PHC approach took place in those years. Government spending for health progressively declined, from 4-5% of total spending in the 70s and beginning of 80s to only 2% in the second half of the 80s. Access to health care further diminished, with only Mogadishu and areas supported by the international community providing  some health services. By the early 90s, an estimated 80% of the population had no access to basic health care. As expected, the impact of 15 years of conflict on the health system has been profound, affecting all its components: human resources, infrastructure, management, service delivery and support systems.

Public Health Care System
Before the collapse of its state in early 1991, Somalia had a public health system –though rudimentary but reasonable by African standards – which had painstakingly been built over the previous 30 years by both civilian and military administrations. The country had a good number of general hospitals (though they were mainly concentrated in big urban areas, like Mogadishu), some regional hospitals, clinics, child and mother health (CMH) centers and out-patient dispensaries. Starting from the early 1970s, for instance, the number of physicians increased significantly, the greater proportion of them being native Somalis. For example, out of about 200 medical doctors in the entire country in 1978, around 120 were Somalis, whereas only 37 out of 96 physicians had been Somalis in 1973. Besides, in the 1970s and 1980s, great efforts were made to increase the number and quality of other health personnel and to enhance the construction of medical facilities. For this purpose, two new nursing schools were set up and several other health educational programs were established.
The opening of the faculty (department) of medicine of the country’s single university, i.e., Somali National University (SNU), Mogadishu, was a very important step in this direction. Another important step was the countrywide distribution, as much as possible, of medical personnel and facilities. Nonetheless, the overall situation of the country’s public health remained unsatisfactory. This is testified by the fact that, prior to the civil war, Somalia’s health sub-sector was significantly under-funded. Less than 2% of the government’s recurrent budget was allocated to health; the average in Sub- Saharan Africa was 6%. The reason for this serious under-funding was obvious, as Siad barre’s military/socialist regime was devoting most of its resources and energy tosecurity and defense, particularly after the commencement of the anti-government rebel movements by 1979. When these armed opposition forces became victorious and the state collapsed, Somalia’s public health – which was essentially funded by the government – collapsed with it. Before this tragic collapse, the organization and administration of health services were in the hands of the Ministry of Health, headquartered in Mogadishu, the capital, with some authority delegated to the regional medical officers. One major function that the ministry used to perform was to regulate both medical and pharmaceutical practices in
the country – an extremely important role. On the other hand, medical services were
practically free for all citizens; but at times you had to buy the prescribed medication,
particularly if it was not available at the government hospitals or public health centers. As such, most Somalis, especially the poor and people with a very limited income could get a reasonable degree of health care, free of charge. Another positive feature of this public health, when the country had a functioning national government, was that Somalia had arrangements with some friendly foreign countries, like Italy, Germany or Egypt, to treat Somali patients or perform surgical operations for them if the required facilities were not available at home. Around 1972, at the start of the application of the “Scientific Socialism” in the country, Siad Barre's regime had banned private medical practice to oblige the small core of physicians in the country to devote all their time and energy to serving their needy people and not to run after personal gains. However, by the late 1980s, the ban on private practice of health care was lifted, after the regime realized that the quality of government health care was unsatisfactory; this started initially by allowing the doctors to practice in their private clinics in the evening,
after finishing their official work in government hospitals.
With the onslaught of the devastating civil war in 1991, the modest health infrastructure of the country was destroyed or seriously damaged; most of its premises were looted, vandalized  or taken over by poor squatters, internally displaced people and at times armed tribal militias. One of the favorite ways of vandalizing these hospitals, clinics and health centers, it was reported, was to take away their wooden doors, windows, marbles (if any) and the plumbing and electric fixtures – after looting the medical equipment- to sell them or to be used for building the looters' own houses or shacks. The famous Mogadishu General Hospital, which used to be one of the most comprehensive and well equipped hospitals in the Horn of Africa – is now occupied by some destitute families. Besides, the well known Medina Police Hospital and Banadir Mother and Child Hospital, all situated in Mogadishu, have been closed down until very recently. These important hospitals were built with funding from the European Union, Italy and China; now some local merchants want to reopen the last two hospitals. But the severest blow that has befallen the country's health system was the departure of the overwhelming majority of the limited number of qualified doctors, nurses, technicians and other medical professionals either for lack of security, work facilities or to find greener pastures abroad; some of them were also murdered during the civil war. Again, as the faculty of medicine of the national university and other educational facilities for training the required medical personnel were either destroyed, vandalized or closed down, no meaningful number of these badly needed staff have been produced in the past 15 years. The numerous yearly scholarships which foreign governments used to offer Somalia to train its future physicians and other medical personnel were also lost during this period as there was no a functioning central government to deal with.

Some Recent Positive Developments
An important positive development was that with the initiative of the few medical professionals who remained in the country in collaboration with some businessmen, some good health care facilities, albeit much smaller than what the country currently needs, have been established. These include general hospitals like Al-Hayat, Arafat and SOS for Children, all situated in Mogadishu. Several health facilities have also been set up in Self-declared Somaliland Republic, chief among them being the modern and well equipped Maternity Hospital which was constructed in Hargeisa at the personal initiative of Mrs. Edna Ismail (Somaliland's current Foreign Minister). Also, in the cities of Bossaso and Galcaio (in the autonomous region of Puntland), some new general
hospitals and other health facilities were established through the help of the local government, businessmen as well as individual doctors who relocated to their regions. In the case of Galcaio, for instance, these new or rehabilitated health facilities serve not only the inhabitants of Mudug region – where it is the capital - but also those of neighboring regions, like Galgudud Nugal and Sol, and even patients from the eastern Somali Region of Ethiopia. On the other hand, the new universities of Amoud, East Africa (Bossaso), Hargeisa and Mogadishu, are also reported to have started to open faculties of medicine within their premises, or plan to do so in future. This would undoubtedly go a long way in addressing the serious shortage of qualified human resources in health delivery and management due to brain drain and lack of training facilities, as alluded to earlier. Periodic immunization campaigns, against polio and other infectious diseases, have been conducted whenever security permits with the help of the specialized UN agencies and donor-funded NGOs. Malnutrition is also reported to have declined, but is still a serious problem in a county ravaged by civil strife and where low rainfall and frequent famines are the order of the day. This malnutrition which, of course, makes its victims more susceptible to more serious illnesses, is said to be prevalent in children between 5 and 13 years old. Notwithstanding the fact that these new medical facilities have been filling in the wide gap that has been created by the collapse of Somalia's public health service, the problems facing the citizens in this regard are huge. For one thing, since these medical services are essentially being offered by the private sector, there is no free or cheap health care in Somalia at all. Everybody, no matter how poor he or she might be, has to pay for it dearly, by local standard. Today, a medical visit costs about So. Sh. 50,000 or around 3 US dollars. This is in a country where nearly 45% of its population in urban areas currently lives in extreme poverty, i.e., less than $1 per day (the situation in rural and nomadic areas is even worse). On top of that, the patient has to undergo medical tests, such as x-rays, laboratory tests, etc., some of which might be unnecessary and which could cost him/her hundreds of thousands of Shillings. In a very poor, war-torn country like Somalia, where avenues for gainful employment are extremely limited, only a minority of its citizens who get regular remittances from their relatives in the Diaspora, can afford this kind of medical fees. Those who are lucky enough or have the means also seek better health facilities in neighboring cities like Dubai, Nairobi, Jeddah or Addis Ababa. Most private hospitals and clinics, everywhere, generate the greater part of their revenues from the above-cited medical tests. It is, therefore, natural that their doctors would often ask people to undergo some superfluous tests, to augment their income.
Apart from that, they could prescribe more medicines than are required – some of it could also be available only in a certain pharmacy that is in collusion with the prescribing physician. But in the opinion of some experts, one of the most serious problems currently facing Somalia's health care system is that there is no governmental authority to regulate this crucial sector. Consequently, in a country whose economy is in shambles, where very few job opportunities exist, where law and order seriously lack, anybody – irrespective of his educational qualifications and work experience – could engage in this lucrative sector. He can then sell his products/services at the highest price possible. Some pseudo-doctors, unqualified pharmacists (or petty traders
in medicine) or ignorant traditional healers could also advise you to take quite inappropriate medicines, which could have serious side effects on your health – and some of which may have already expired. There is a functional the Ministry of Health in Puntland which has a policy and strategy framework. However, resources available to the Ministry are limited and its role has been primarily to coordinate the activities of international agencies and NGOs as well as local NGOs who support health services and responsibilities that were previously
handled by the Ministry of Health during the pre-war period. Improving the health of the population of Puntland through increased access to health services is the goal of the Ministry of Health. In order to improve health services in urban areas that have higher population densities, the International and local NGOs have constructed MCHs and health posts. CHWs and TBAs have also been trained on basic health services.

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