It’s been 13 years since I last visited Somalia and, in particular, the state of Puntland. It was during my last year of graduate school and I was there to conduct qualitative research for my Master’s thesis.
I spent six weeks travelling throughout the state, interviewing health care providers and women about their healthcare experiences in every stop — from the coastal town of Bandar Beyla, where my father was born, to major cities like Bosaso and Galkacyo and every other town in between.
Conducting my research, although challenging, was very meaningful. It helped me to understand the many obstacles, as well as opportunities, facing healthcare providers who work in the region. I developed a deeper appreciation for the brave women and men working in under such difficult circumstances.
As a nurse, I knew what it was like to work in under-resourced healthcare environments in the US, and as challenging as these experiences may have been, in no way did they prepare me for what I eventually witnessed in Somalia. For example, life expectancy, at the time, was less than 50 years, and maternal and infant mortality rates were among the highest in the world.
Fast forward to 13 years, and I am now living in Nairobi, Kenya — having just returned from my second trip to Garowe, the capital city of Puntland. During my visit to the capital, I met with the minister of planning and international cooperation and his staff who recently published first of its kind population data booklet that included health metrics. I was able to revisit the Ministry of Health and Garowe General Hospital, where I was pleased to see that notable progress had been made.
The MoH is now well staffed with highly qualified leaders and health professionals. And although still under-resourced, Garowe General Hospital, which serves as a regional referral hospital, has an improved infrastructure, better equipment and some of its employees are from the Somali Diaspora — experts in their respective fields. Implementing key projects and providing ongoing training and support to local staff are just some of their required daily duties.
The facility has a newly built child-feeding center and a neonatal intensive care unit — two important investments in a region that has one of the highest rates of child malnutrition and infant deaths in the Horn of Africa. The hospital also provides a pipeline for future healthcare providers as it trains students from local universities and colleges.
Several transformative projects are still in development. For example, with funding from UNFPA/Sweden in Somalia, the ministry is now in the process of training hundreds of nurse-midwives who could be deployed to the region and especially in rural parts of the state where the need for maternal health care is at its greatest. The training includes payment incentives so they stay in their local communities, and aren’t enticed to venture out to bigger cities where salaries or reimbursements might be higher.
Growing and improving nurse-midwifery training programs is critical to Somalia’s health system as women of childbearing age are 25% of the population. Without these well-trained nurse-midwives, it’s almost impossible to improve the health of mothers and young children in the country. According to the World Bank Group, there are less than 4 nurse-midwives for every 10,000 individuals in Somalia compared to 15 for the same amount in neighboring Kenya.
Another beacon of hope for Somalia’s healthcare is how steadily Puntland’s healthcare workforce is diversifying and growing, even though the supply is still much lower than demand. In addition to nurses, midwives and doctors, there are more schools and training facilities than ever before to educate nutritionists, emergency medical technicians, public health professionals, among others.
Access and availability of health services in the private sector is also improving. There’s a growing number of Somali entrepreneurs who are operating health centers, ambulance services and pharmacies which give healthcare consumers quality care, choice and flexibility, provided that they can afford these services.
Despite these positive improvements, challenges still remain. Cost of healthcare is still high for the population and a growing number of women are continuing to deliver at home due to concerns relating to cost, safety and quality of care at certain facilities.
Rates of vaccinations and pre-natal care are low compared to neighbouring countries. Ensuring the safety of the medications sold in the market is a challenge. Patients with chronic conditions, such as diabetes and hypertension, do not have access to the care and/or medications they need to maintain their health — this inevitably forces a large number of them to travel to neighbouring countries for their care or succumb to organ failures.
Screenings or diagnostic tools for cancer are not available to a majority of the population. Access to mental health and substance abuse treatment is limited. Recent droughts and other humanitarian disasters have added additional burdens to the system by shifting the political focus from providing basic health care to emergency response.
On the whole, I’m glad to see that Puntland and most of Somalia’s health care improvements are led by national and state level ministries of health, but it’s fair to point out that current funding is still insufficient and heavily dependent upon international NGOs, the Somali Diaspora and foreign donors.
Since 2015, investments in Somalia’s health care system have increased three-fold from $53.6 million in 2005 to $150 million in 2014. As a result, health outcomes have slightly improved for the population as a whole. In particular, the past ten years has seen a statistically significant decrease in both maternal and infant mortality rates in Puntland and some other parts of Somalia.
It’s not clear whether these foreign investments will be maintained or increased in the coming years. Therefore, as the country’s revenues and financial systems improve, national and local governments must take greater roles in financing the public health and primary care system. It’s also important for the government to work and build partnerships with donors, humanitarian agencies and entrepreneurs so that together they may create a long-term vision for achieving measurable, and sustainable, development goals for the better health of all Somalis.