Hiiraan Online

by Mohamed Ali Magan
Saturday July 16, 2022

Leading and engaging in public health programming in a vulnerable context like Somalia supposedly needs more than the usual ways of doing business. Using an experience of more than ten years in public health programming in a post-conflict setting, the unprecedented climatic shocks, outbreaks, armed conflicts, and other recurring humanitarian crises have an impeding effect on re-establishing a more robust health system in Somalia. There are various reasons why these challenges are recurrent, and one obvious reason could be the government’s limited resources in investing in health infrastructures. According to World Bank (2021), the Federal Government of Somalia (FGS) allocated only 1.3% of its annual budget to the development of the health sector, which is much below what African member states agreed (15% of the yearly government budget) when they met in Abuja in April 2001.

During this meeting in Abuja, the African Union members acknowledged that more health resources were needed because of the emerging and re-emerging diseases and the need to address the pressing health challenges of the day, including HIV and AIDS, Malaria and Tuberculosis.  However, the sad reality is that even though many African countries have marginally increased their health spending overall, only a handful of countries – not as many as the fingers on one hand – have met this target in any given year. In 2018, only two African countries met the target (Africa Renewal report, 2020)

With less than 1.5% government budget allocation for health, one can ask, how do Somali people access public health care services? Though many people worldwide could have the same background risk of developing the diseases, Somalis children experience excess risks due to their lack of access to some vital childhood vaccines that have not yet been introduced in the country, such as the Pneumococcal Conjugate Vaccine (PCV) and rotavirus vaccine which could have been used to prevent more than 25% of the childhood mortalities attributed to pneumonia and diarrheal diseases, World Health Assembly (May 2022). Like any other human being, Somalis deserve protection for themselves and their beloved ones from facing financial crises and catastrophic costs related to health services.

To give you an answer to the question above, the public health services delivery largely depends on the generous contributions from bilateral donors, UN Agencies, and other global programs like the Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM) and the Global Alliance for Vaccines and Immunization (GAVI), mainly lifesaving or humanitarian and a few developmental health projects implemented jointly by the government and health partners.  One may ponder how public health services, especially health services delivery, can depend on a project-based and donor-funded service delivery approach, but that is another sad reality! Due to the limited annual government budget (less than a billion) and the other contending national priorities, including security, the health sector did not yet have well-deserved government attention, and the poor children and mothers most pay the price.

Maybe you are among them, but for those who can understand the nature of projects, both humanitarian and developmental interventions, some keywords or project constraints that can immediately come to mind are time, scope, and cost. This means a given project should be delivered within a specified timeframe and achieve the predetermined targets within the given budget. Suppose you think health is a fundamental human right and that accessing quality health services (when and where they need them, without suffering financial hardship) is a global imperative for universal health coverage. In that case, I can 100% agree with you, but upholding this promise in a context where the government budget for health is almost nonexistent would need other discussion forums.

More to remind you, most donor-contributed health project identification, development, and designs are based on specific parameter assumptions, including the time need, catchment population and the available resources (budget). However, all these programmed parameters can quickly change due to climatic shocks (i.e., drought/floods) and/or conflicts during the project implementation, leading to an increase in the catchment population and significantly increasing the need for health services.  The common outbreaks in Somalia, such as AWD/Cholera, measles, and other CDs, can also quickly erupt during the project life span. On top of this, the service delivery gaps are inevitable realities in the contexts like Somalia. The latter can force more beneficiaries to seek assistance from the sister project-supported facilities. All these unforeseen events will put more pressure on the limited and predetermined project resources, including the supplies, the human resource/services providers, and the space, which will directly or indirectly affect the quality of the service delivery. Therefore, though this triple constraint of the project guides the overall implementation of the programs, driving within these constraints will always be a challenging experience in the contexts like Somalia. The dimensions of health services quality, including interpersonal relations, access to the health care services and the continuity of the service, physical infrastructure, and comfort of the facilities, can easily be damaged.

World Health Organization (WHO) categorises the situation of Horn of African countries, including Somalia’s current situation, as grade three of emergency, the highest emergency grade.

The current drought's impact on the population's health is alarming. Families are currently taking desperate measures to survive, with thousands leaving their homes, increasing health risks and needs, especially for pregnant and lactating mothers, newborns, children, the elderly, and people with chronic diseases and disabilities. In the areas affected by the drought, epidemic disease outbreaks are significant public health concerns, especially considering the low immunisation rates and insufficient health service coverage.  Key health risks over the coming months include increased malnutrition rate, acute watery diarrhoeal diseases including Cholera, measles, malaria, and sexual and reproductive health. Some of these risks, including malnutrition and acute watery diarrhoea, are already certain to happen. These major public health concerns can result in high excess mortality/morbidity levels.

Potential approaches to maintain the quality of the existing health services delivery and to respond to the growing health services needs during shocks

Firstly, considering the global crisis and the increasing climatic shocks in the horn of Africa, it’s high time for the government to revise its priorities as the duty bearer and prioritise the national health sector. Therefore, encouraging the government to at least allocate an emergency fund for the current crisis and to prioritise the health sector in the coming government annual budget could be an option to explore. Secondly, the integration of humanitarian funding mechanisms into the donor-supported developmental health programs (Crisis Modifiers budgets) so that the programs can respond more quickly, reliably, and effectively to the changing needs can help maintain the quality of the existing health services delivery during crises and protect the gains/progresses made by the ongoing projects. Furthermore, accessible funds (pre-arranged financing) for anticipatory health actions (i.e., the preposition of medical supplies, including the IDDKs) could help strengthen the early warning systems and timely response to the hazards or disease outbreaks, and it helps in the prevention and mitigation of related morbidities and mortalities. Finally, adaptive programming is a potential approach to explore during emergencies to react and respond to the changes in health needs by adjusting the planned actions/budgets to find workable solutions for the diminishing resources, such as medical supplies and human resources for health.