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Article: After Years of War, the Fight for Health

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Article: After Years of War, the Fight for Health

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The country went through a harsh civil war. The country had lack of healthcare and healthcare workers. They are fighting for healthcare.

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Over 26 years of civil war in Somaliland completely decimated its health services. In the chaos, many health care professionals were either killed or fled the country, more than half a million people lost their lives, and a further million became refugees. Civilians were subjected to genocide and mass killings, and health facilities were razed.

But in 1991 Somalilanders claimed independence from Somalia and focused on rebuilding their lives-and health services-ever since. And although some health facilities have been rebuilt, or built from new, like the Edna Adan Hospital in Hargeisa, Somaliland continues to suffer from a severe shortage of trained health professionals and appropriate medical equipment.

In response to this need, a global collaboration in the shape of a public-private partnership (PPP) emerged to improve the quality, safety, and access to surgical care in this region.

By definition, access to safe surgical care means access to safe anesthesia-which an estimated 5 billion people around the world do not have. SANSOM, or Safe Anaesthesia for Somaliland, brought together 5 international organizations-a charity, a foundation, 2 NGOs and a commercial business-to make a small but meaningful dent in this statistic.

Building on 2 years of training for nurse anesthetists by Mark Newton, MD and his colleagues at AIC Kijabe Hospital, Kenya, a January 2017 conference at the Edna Adan Hospital in Hargeisa gathered students from across Somaliland for further training, and to consolidate and strengthen their knowledge.

Now, there are more than 30 well trained nurse anesthetists working in Somaliland. And although there is still not a single consultant anesthesiologist in the country, SANSOM ensured that all 6 regions of Somaliland now have a provision for skilled anesthesia care in the shape of nurse anesthetists.

A parallel initiative driven by Diamedica UK Ltd, SANSOM aimed to train and equip newly qualified anesthesia providers with appropriate equipment, such as portable anesthesia machines, oxygen concentrators, pulse oximeters, and more.

Despite well-intentioned donations from the west, suitable medical equipment for low-resource settings can be very hard to come by. Indeed, western donations can often become abandoned 'apparatus graveyards' of machines. That's because this equipment can't function in a remote field hospital where there may be an erratic electricity supply, unavailability of compressed oxygen, an absence of biomedical engineers familiar with the equipment, or no access to spare parts for repairs.

Crucially, the portable anesthetic machines donated for SANSOM-accompanied by oxygen concentrators to address oxygen shortage problems-were designed for optimum functionality in low-resource environments.

Medical staff in Somaliland are as conscious as anyone else in the world of the challenges set by the UN's Sustainable Development Goals-in particular SDG3, on Health and Well-Being. They also aspire to Universal Health Coverage, but here, with one of the highest infant mortality rates in the world, one in 7 children won't reach their fifth birthday. Their mothers face a lifetime risk of one maternal death for every 10 women.

Since surgery can successfully treat conditions from cancer to obstructed labor, access to safe, timely and affordable surgical care and anesthesia is essential for these at-risk women. Reports from the hospitals that participated in SANSOM confirm improvements have already been made in reducing both infant and maternal mortality. What's more, for the first time in the country's history this data is being recorded on tablets donated as part of the project.

Initial assessments following SANSOM show that it is possible to make a huge difference on a comparatively small budget, fueling optimism in the participating medical staff. Keys to success, according to SANSOM, includedbringing an appropriate innovation to the development table-in this case, a portable anesthesia machine and oxygen concentrator exclusively designed for challenging environments.

The project also adopted a community-centric approach, using a sustainable education model to counter 'brain drain' with an emphasis on homespun training and follow-up opportunities. The donated equipment also gave newly trained nurse anesthetists a way to practice their new skills, and the potential for rewarding medical careers at home.

SANSOM's lessons showed that practical solutions aimed at a critical need-the lack of surgical access in Somaliland-can save lives, and provide a model to help close a persistent health disparity between the West and low-income countries.

Andrea Charters is the Communications Executive for Diamedica UK Ltd, a journalist, former newspaper sub editor and recently the editor of two international medical journals. She writes extensively on global health matters and directed an award-winning documentary film on this subject, SANSOM - Partnerships for Progress, in Somaliland.
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After Years of War, the Fight for Health

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Over 26 years of civil war in Somaliland completely decimated its health services. In the chaos, many health care professionals were either killed or fled the country, more than half a million people lost their lives, and a further million became refugees. Civilians were subjected to genocide and mass killings, and health facilities were razed.

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Peer review: Capacity Building Within Health Care in Somaliland

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Peer review: Capacity Building Within Health Care in Somaliland

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Training, supporting, and aiding in many disciplines of healthcare. The article talks about the how it helps the healthcare workers, as well what did not work. The article gets into the healthcare system, and what the disciplines that they were supporting.

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In the beginning of this video the nurse who was a diplomat in the WHO, speaks about the history of Somaliland. She also speaks about the lack of medical professionals. She helped train people in the healthcare field in Somaliland, which in turn helped the healthcare system.

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How women reduce maternal mortality in Somaliland | Edna Adan Ismail | TEDxAmsterdamWomen

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We went over this topic in class. I thought that it was an interesting article to read because it talks about how stopping the defecation in the open will help public health. This is not the health care system, but thought it was good to add!

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Sa'ado's toilet is a pit latrine. Shielded by pieces of bright orange cloth sewn together and covered with dried, thorny branches, it stands at the edge of the family's compound.

"The children in the village used to have diarrhoea a lot," says Sa'ado. "But since we built the toilets, we have hardly seen any cases."

"Many families welcomed the idea right away but many resisted it," says Adan Abdullahi Mohamed, Programme Coordinator at HEAL. "The key to the success of the project is to make the people understand that open defecation is an unhygienic practice and causes serious illnesses, especially for children and pregnant women."

"When the community realized that the river where they get water their drinking water was contaminated by their own faeces, they were convinced that a toilet is not a luxury but a necessity."

In Somalia, 37 per cent of the population practice open defecation - one of the primary causes of diarrhoea.

In 2012, UNICEF began the project in 60 villages throughout Somalia. Today 12 villages in Somaliland, including Sa'ado's, have achieved the status of 'open defecation free'. Two villages in Puntland, and 25 in Somalia's central and southern regions have received the same certification.

On 19 November, World Toilet Day, Sa'ado and her family joined their neighbours, government officials and UNICEF staff in a ceremony to mark the official declaration of open defecation free for the villages.

"We knew from the start that we would benefit from the toilet," says Yusur Abdillahi of Hirsi Jicir, one of the villages declared open defecation free. "We now have a place that gives us privacy and convenience. When new people come and want to settle in our village, we ask them to dig first, or we will not welcome them," she says, standing proudly next to her toilet.

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Somaliland villages lead the way to stop open defecation

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Sa'ado's toilet is a pit latrine. Shielded by pieces of bright orange cloth sewn together and covered with dried, thorny branches, it stands at the edge of the family's compound. "The children in the village used to have diarrhoea a lot," says Sa'ado. "But since we built the toilets, we have hardly seen any cases."

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Video: Global Health Organization Providing Healthcare and Training Video

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Video: Global Health Organization Providing Healthcare and Training Video

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The organization address the lack of healthcare workers and healthcare. They are providing training to workers and institutions, trying to improve community health, and providing healthcare for minor illness.

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Video: Healthcare progression in Somaliland 

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Video: Healthcare progression in Somaliland 

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In Somaliland, there is a lack of anesthesia. But for the first time there will be different locations with it. There is now trained technicians, support, and knowledge in Somaliland. This is saving the lives in this country.

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SANSOM - Safe Anaesthesia for Somaliland - Partnerships for Progress

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Video/Article: Helping the shortage of Healthcare workers in Somaliland

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Video/Article: Helping the shortage of Healthcare workers in Somaliland

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Aid for the UK is sent to Somaliland. The video and article go over how the lack of healthcare workers is affecting the country. There is numbers in the article how this reform is improving numbers and education in the country.

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Meeting Somaliland's health needs through practice-oriented higher education - Prepared for Practice

Somaliland's poor health indicators are in part driven by a shortage of well-trained health workers. This health workforce challenge is rooted in issues in the tertiary education sector: critical gaps in the curricula, insufficient expertise within universities to design and deliver relevant courses, limited formal pedagogical training amongst faculty and lack of opportunities for students to develop skills in clinical settings. As a result, graduates often lack the knowledge, skills, behaviours and practical experience to deliver safe and quality healthcare.
The Prepared for Practice (PfP) partnership addressed Somaliland's health workforce challenge through an integrated approach to health education system reform with interventions at individual, institutional and national level.
The approach
Improving undergraduate teaching, examination and clinical supervision

Online tutorials to medical, nursing and midwifery students provided by UK health experts

Supervision of hospital ward rounds and field trips to health facilities

Evidence-based examinations

Strengthening capacity of academic staff and teaching institutions

Certificate, diploma and master's level courses in health education

Postgraduate certificate in administration

Supporting national policy and regulation

National medical education policy

Standardised national medical curriculum

Highlights

1,800medical, nursing and midwifery students reached, including 838 through PfP's online learning platform

77% of medical and 93% of nursing and midwifery undergraduates surveyed feel prepared for practice

144 NHS volunteers delivered online undergraduate tutorials 16different departments at three universities positively impacted by the HPE

129 teachers and administrators benefitted from capacity development

24 clinical supervisors trained and supported

12 unique online courses collaboratively designed and delivered with partners

The partners

The PfP partnership was led by King's Global Health Partnerships, an initiative of King's College London (UK), working with Amoud University (Somaliland), Edna Aden University and Teaching Hospital (Somaliland), University of Hargeisa (Somaliland), MedicineAfrica (UK), and the Tropical Health and Education Trust (UK).

Find out more

PfP summative evaluation: Read the executive summary of the report.

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Somaliland's poor health indicators are in part driven by a shortage of well-trained health workers. This health workforce challenge is rooted in issues in the tertiary education sector: critical gaps in the curricula, insufficient expertise within universities to design and deliver relevant courses, limited formal pedagogical training amongst faculty and lack of opportunities for students to develop skills in clinical settings.

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Peer review: Strengthening the Somaliland health system by integrating public and private sector family medicine

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Peer review: Strengthening the Somaliland health system by integrating public and private sector family medicine

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This article speaks how adding both the private and public sector may help the healthcare system after the civil war.

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Background

Civil war broke out in Somalia in 1988. By 1991, the clans in the northwest of the country declared independence and formed a new country, Somaliland. Whilst the rest of the world does not recognise it as an independent country, Somaliland has developed relative peace and stability in contrast to the rest of Somalia. The estimated population of Somaliland is 3.8 million, with 45% population living in rural areas. Farming livestock is the backbone of the economy. Life expectancy is 55 years and the maternal mortality ratio is 396 per 100 000 live births.

The Somaliland health system is based on an Essential Package of Health Services (EPHS), which the government adopted in 2009. The EPHS describes four levels of service delivery: the primary health unit, health centre, primary hospital (also known as the first referral hospital or district hospital) and regional hospital. The primary hospital is meant to be served by generalist doctors whilst the regional hospital is organised according to traditional hospital specialties.

Amoud University, Somaliland's first institution of higher education, was founded in 1998 in Borama, a town with a population of about 150 000. Amoud Medical School started in 2000. In 2012, four United States (US) trained doctors partnered with Amoud University to establish a family medicine training programme as a master's degree (MFamMed). At the time there were no specialty training programmes for doctors in the country. During their three years of training family medicine registrars become competent to accomplish two main tasks: firstly, to provide comprehensive, holistic care at the level of the primary hospital, and secondly, to work alongside teams in the hospital's catchment area to provide primary health care. Since the start of the programme 29 family medicine specialists have graduated.

In the Borama District public sector there are 13 health centres, one functional primary hospital and one 377-bed regional hospital. Because there is only one primary hospital in the system, the staff of most health centres refer patients directly to the regional hospital when the patients need higher level care.

In 2020, the Somaliland government implemented a policy to provide free care for obstetrics patients delivering in government health centres or at the regional hospital, if the patient is referred there from a health centre. There is no mechanism to include the private sector in this service.

The first four authors of this article are women who became friends whilst studying in medical school at Amoud. After graduation from medical school they joined the family medicine training programme and finished it in 2015 and 2016. By 2017, they had established a practice that informally brought together the public university, the public regional hospital, their own private hospital and the public primary care system.

Amoud University initially employed them as clinical instructors of medical students and interns at the public regional hospital. Later the university increased their teaching responsibilities by appointing them as either full or adjunct faculty members of the family medicine training programme, which uses the regional hospital as its main teaching hospital. Muna M. Mahfud is the director of family medicine training.

When they began work for the university at the regional hospital, the hospital had only two specialists. The hospital soon appointed them to clinical governance positions: F.M.N. is the hospital medical director and S.M.M. is in charge of the adult medicine service. H.J.A. founded the hospital's neonatal intensive care unit (NICU) in 2017. This is the only NICU in the region. In 2020, the NICU had 264 admissions and an 85% survival rate. H.J.A. remains in charge of the service.

The fifth author of this report (T.F.) taught family medicine from 2012 to 2015. He then left Somaliland and returned in 2021. The improvements in healthcare at the regional hospital are remarkable. The family medicine faculty members and registrars brought to the hospital evidence-based standards of care, professionalism, morning report, morbidity and mortality review, improved documentation, daily rounds, regular teaching and dependable backup at night and on weekends.

Because of the specialist compartmentalisation of the regional hospital, the four family physicians were not able to practice comprehensive family medicine. In 2017, there were no primary hospitals in the Borama public sector at all. Thus, the four women decided to form a legal partnership and open their own private hospital.

They rented adjacent houses in an underserved area of town and set up inpatient and outpatient services including laboratory, ultrasound and pharmacy. They advertised their hospital through local television for two months and through patient education articles on a Facebook page for a year. They established a graduated fee-for-service billing system that facilitated access to their care by the poor in the community. They connected with nearby health centres and offered to care for their complicated patients so that they would not need to be referred to the regional hospital.

They opened all services on 7 October 2017. On the first day, they had to do a C-section on a midwife from a village in Ethiopia. Mother and baby did fine, and the relatives were surprised that women could do surgery. Box 1 shows characteristics of Awdal Hospital for the year 2020.

Discussion

The public sector health system in Borama district does not function as envisioned by the EPHS. Because of a lack of public sector primary hospitals, staff at health centres refer patients directly to the regional hospital. However, there are now 10 private primary hospitals in Borama district. The government could improve the delivery of health services in Borama district by contracting private primary hospitals to fill the gap between health centres and the regional hospital. Contracting private sector services is a main goal of the Somaliland Ministry of Health Development.

The government policy to provide obstetric care free of charge is a reasonable strategy to decrease maternal and neonatal mortality by increasing facility-based deliveries. The government could broaden the impact of this policy by including the option to deliver at approved private primary hospitals. This change would increase accessibility of care and would lead to more appropriate use of the regional hospital.

Because of a lack of specialists in the country, the regional hospital fills its staffing gaps with family medicine doctors. This approach has had good results at the regional hospital and is a reasonable short-term answer to the shortage of specialists. Ultimately, however, as other specialists become available for the regional hospital, the health system will function better with family physicians working at the primary hospital. This is the goal of the family medicine training programme and is consistent with the most common deployment of family physicians in sub-Saharan Africa.

Whilst the same four doctors apply the same standards of care and spend about the same amount of time working in the public and private hospitals, they know that their impact on patient care is greater in their own hospital. Why is this? The answer is multifactorial, but this group believes the main reason is that they have administrative authority over the structure and process of care in their private hospital, but not in the public hospital. Whilst they have positions of responsibility in the public hospital, they lack the authority to carry out those responsibilities. Having appropriate authority to accomplish their clinical governance responsibilities would increase their impact on healthcare at the public hospital.

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Strengthening the Somaliland health system by integrating public and private sector family medicine

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Civil war broke out in Somalia in 1988. By 1991, the clans in the northwest of the country declared independence and formed a new country, Somaliland. Whilst the rest of the world does not recognise it as an independent country, Somaliland has developed relative peace and stability in contrast to the rest of Somalia.

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Article: Slowly and steadily, Somaliland builds its health system

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Article: Slowly and steadily, Somaliland builds its health system

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Article talks about how the country is starting to build up the health care system with help from organizations.

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Slowly and steadily, Somaliland builds its health system

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Somaliland has made impressive gains in strengthening its health services, but substantial
challenges remain for the unrecognised nation. Sharmila Devi reports from the capital
Hargeisa.

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Peer Review: Somaliland Health and Demographic 

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Peer Review: Somaliland Health and Demographic 

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This demographic survey was the best resouce that I found to understand Somaliland's main health issues. There is over 400 pages in this. To narrow down your search and interest on page 10-14 it tells you all the contents that you can cover.

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Somalia's Women and Children are Among the 1.84 Million to Benefit from Improved Healthcare Services. 

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World Bank approves funds to help healthcare in Somaliland

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World Bank approves funds to help healthcare in Somaliland

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Somalia's Women and Children are Among the 1.84 Million to Benefit from Improved Healthcare Services

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The World Bank approved the Improving Healthcare Services in Somalia Project, known as "Damal Caafimaad," which is financed by a US$75 million International Development Assistance (IDA) grant and an additional US$25 million grant from the Global Financing Facility for Women, Children and Adolescents (GFF).

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Global Health Partnerships to assist Somaliland 

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Global Health Partnerships to assist Somaliland 

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This article from Tret shares a little bit about the healthcare that Somaliland has. During the Civil War Healthcare was poor. To help with the healthcare crisis in Somaliland there are several projects that Global Health Organizations are doing. Just some of the organizations are Kings Global Health, Ministry of Health Development (MoHD), National Health Professions Commission (NHPC), Lifebox Foundation and the World Federation of Societies of Anaesthesiologists. Towards the bottom to the article, it shares several projects that these organizations are doing to help healthcare in the country.

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THET has been working to improve the capacity of Somalia and Somaliland health workforces since 2000 and in 2011 opened a Country Office in Hargeisa.

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Peer Review: Medical treatment and medication

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Peer Review: Medical treatment and medication