Source: World Health Organization
Politics and health
Peace talks raise health hopes
With peace talks in Djibouti coming to the end of the second phase, hopes are rising that they may bring agreements that will allow big changes in health.
"If the peace talks succeed in establishing some form of overall government, it will enable us to make some dramatic moves forward on health in Somalia," says WHO representative, Dr Najibullah Mojadidi. "Firstly it would give us a counterpart to work with across the country which would streamline the development and implementation of programmes.
"Secondly it would open up access to areas which have been long neglected because of insecurity, though this will also increase the needs for action tremendously. And thirdly, peace would allow us to move into more developmental programmes that will have a long term impact on health."
But issues such as government-building and disarmament are among the most highly sensitive, and observers say that though the peace talks have brought many people from inside and outside Somalia together for the first time, the outcome is still far from certain.
On the positive side, says Dr Mojadidi, many Somalis are seeing the peace talks as a real opportunity to break out of the chaos of the past.
"But danger is that if the talks break down, things will get worse rather than stay the same. There would most likely be renewed fighting which will not only damage access but put donors off even more. We raised US$I million for TB this year (see page 2) I doubt we could do that again if the peace talks fail. My personal view is that this is the last chance for Somalia to solve its political problems."
New body seeks collaboration
A joint health authority made up of doctors who have remained in the capital has asked UN agencies for help to try and kick-start some of the basic health services long abandoned in the capital. One of the priorities expressed is re-establishing city-wide routine childhood immunization.
Although UNICEF supports several mother and child health units, childhood vaccination is limited by the lack of freedom of movement. However, recent initiatives which have seen clans and JHA members come to together on technical committees to plan polio immunization days across the city (see page 3), have raised hopes that this kind of co-operation could be expanded into other areas.
There are also signs of change in the city itself. There is, for example, a hive of building activity, either starting afresh or renovating of damaged section, and where once the only public vehicles available looked like they were held together by prayer alone, now there are a plethora of new vans and jeeps fresh from Dubai.
Business is flourishing too: computers, fridges, designer watches, the latest model of mobile phone can be acquired in the city market far more rapidly and cheaply than in neighbouring Kenya.
However, few of these developments have rubbed off on the quality or extent of health services available for most of the population.
Data systems go live for 2000
After 10 years of haphazard information flow on health, this year has seen the start of two new information systems that should have a big impact on the effectiveness of programmes in Somalia.
The routine health information system, which has been in the pipeline for over five years, and the rapid outbreak detection network are collaborations between WHO, UNICEF, the World Food Programme, the United Nations Development Programme and almost 20 health NGOs sited across Somalia.
Designed to collect basic health data from primary care facilities, the routine system was field tested by NGOs including Memisa, the International Federation of the Red Cross, World Vision, the Italian International Committee for the Development of Peoples, the International Committee of the Red Cross and International Medical Corps in late 1999 and went live in March.
It involves a standardised form and monthly reporting for health conditions, using whatever means of communications means are available, including radio, telephone, fax and email. Immunization and nutrition data are also included and all the data ends up on the computer of WHO Somalia health information officer, Farah Dar in the Nairobi office.
What finally got the system off the drawing board and into the light of day was the urgent need for baseline data, she says. "There was a lot of delay due to changes of personnel and intentions among the working group. But now the system will be able to supply agencies working in the field with data, facts and statistics that will assist them in developing, implementing and managing their programmes. It will also give donors more concrete information on which to make funding decisions."
Most donors have agreed to write use of the data collection forms into their funding contracts, she adds.
The outbreak detection system, which went live on 6 May 2000, uses a similar reporting set-up but is based on 17 sentinel sites which, by the end of July, should be providing weekly information on four key conditions cholera, meningitis, measles, blood diarrhoea and any other disease outbreaks from 13 of the 18 regions of the country.
Again the material comes to Ms Dar who tracks the trends so as to allow early reaction to any epidemic threats.
Despite enthusiasm from NGOs and local health workers, the introduction of both systems has not been without hiccups. Data flow is still quite erratic especially from local authorities, says Ms Dar, mostly due to the lack of health information experience among Somali staff. But more training, due to take place next month, should improve things.
Somali cure rate beats US
TB treatment centres in Somalia are achieving better cure rates than United States. But more treatment centres still are needed to combat the condition which, with malaria, is the number one source of illness and death in the country.
While US cure rates languish at between 50 and 70% due to increasing drug resistance and the breakdown of the public health system, Somali centres consistently average over 88%, according to WHO medical officer for TB in Somalia, Dr Firdosi Mehta who says the success springs from the combination of Directly Observed Therapy Short Course (DOTS) strategy, dedicated Somali staff on the ground, and WHOs commitment to supply a continuous supply of free drugs.
"In the past two years DOTS access has expanded from 44% to 56% of the country," he told Somalia Health Update.
Three new centres were started in 1999 and two more, in Mogadishu and Adale, re-established, taking the total to 11. Seven more are scheduled to open in 2000 as a result of funding from the Norway Government (see below).
While WHO provides the entire logistical support system for the TB programme including a continuous supply of drugs, equipment and training activities, nine NGOs and one individual operate the centres.
"The strength and sustainability of the programme is that it is Somali staff who do the day-to-day work." notes Dr Mehta. "The NGOs provide salaries and the environment, but it is the Somalis who are doing the job of treatment."
Somalia is estimated to have one of the highest rates of TB incidence in the world with around 12,000 sputum positive cases occurring a year, or roughly 200 cases per 100,000 population.
Less than 30% of these are currently detected 4784 cases in 1999 but detection rates have more than doubled in the past five years as a result of the programmes focus on treatment of sputum positive patients who are the key to reducing the pool of infection.
Interestingly, conflict-ridden Somalia is making more headway with DOTS than its more stable neighbours despite most patients having to travel to the centres several times a week for six months for treatment.
"TB control with its need for long term treatment is challenging in conflict situations like Somalia, but it is a matter of will and management," says Dr Mehta. "We use a dameen or guarantor system in which a family member, a respected person, or an authority in the community vouches in writing that the patient will complete treatment. In some areas there is a cash deposit, and in others patients who default spend a day in gaol to emphasise the importance to the community of completing treatment. But remember these are local initiatives there is no government to enforce them."
For information on TB in Somalia, or to receive the quarterly TB newsletter, please contact Dr Firdosi Mehta, ph: +254 2 623 197/8/9, email: firstname.lastname@example.org.
Kat sessions carry extra risk
Kat, or in Somali parlance, miraa may be one reason why a third more men report with tuberculosis than women.
Not only do miraa chewing sessions usually take place in crowded claustrophobic huts with doors and windows closed, but the woody stalks are also a stimulant that reduces desire for food, leaving chewers malnourished and less resistant to infections.
However, the disparity can also be explained by the fact that women usually only come to TB centres when their condition is very serious due to family commitments and fear of exposure.
Norway backs DOTS expansion
The Norwegian Government has allocated almost US$1 million to WHO to maintain the TB programme in Somalia for three years.
Most of the donation will arrive in the form of hospital and laboratory equipment, supplies and drugs which will be used to expand the existing network of TB centres into so far unserviced areas.
WHO is the lead agency in TB in Somalia and unusually provides not only the traditional technical advice but all logistics, training, reporting systems laboratory equipment and drugs.
"In special circumstances we have to cross the line of our mandate to implement programmes of crucial health importance if no one else can or will. TB is one of those circumstances," says WHO Somalia medical officer Dr Firdosi Mehta.
Until now the TB programme has been funded from the country offices regular budget. However, the welcome windfall from Norway will allow the intensity of the tuberculosis programme to continue alongside the development of other pressing programmes such as epidemic response, malaria control and reproductive health.
Teamwork Tackles TB:
|Centre support and operation:||
SAACID Somali NGO Hope,
Mercy Corps International
Médicins Sans Frontiéres Belgium
Kuwaiti Joint Relief Committee
African Medical and Research
Norwegian Peoples Aid
Annalena Tonnelli Centre (see box)
|Day to day activities||Trained Somali health workers|
|Logistics, drug supply, laboratory equipment, training, data flow:||World Health Organization|
New century, new approach
After years of trying to fight malaria with everything from larvivorous fish to breeding site destruction with little success, UN agencies, NGOs and Somali health workers are this year hoping to deal the disease a real blow by taking on WHOs Roll Back Malaria programme.
Funded by a consortium of donors through WHO headquarters in Geneva, the programme combines health education, household spraying, impregnated bed nets and laboratory supported treatment to reduce resistance.
WHO Geneva malaria expert Dr Eliab Seroney is currently in Somalia laying down a Roll Back Malaria plan of action for the country which sees seasonal epidemics in the North and persistent endemic disease in the South and Central regions.
Laying the foundations for the programme, WHO Somalia laboratory expert, Mr Peter Arrube has been establishing laboratories throughout the country and training nationals in malaria microscopy. Some 4,000 bed nets made from insecticide impregnated material provided by WHO have also been manufactured in Merka for distribution in endemic Lower Shebele.
Warring clans fight polio
The first polio immunization days in Mogadishu for two years have achieved good coverage and raised hopes that the viruss days may be numbered.
Coverage in the first round which took place in May averaged between 95% and 130% evidence of how difficult it is to obtain accurate estimates of the target population), and results from the second round held in June are expected to be at least as good.
Violence and running battles prevented the campaigners from covering Mogadishu during country-wide immunization days in 1999, and fighting in one district which left 30 dead and 50 injured plus the looting of vaccines from a car crossing the Green Line the day before the second round, started, threatened to sink these sets of specially targeted days.
But meticulous sub-district by sub-district planning and training by WHO and UNICEF national and international staff paid off and allowed teams this time to work around trouble spots and reach the estimated 200,000 children who live in the capital.
Organising NIDs in a place like Somalia contains all kinds of hidden pitfalls for the unwary. Delicate negotiations are required, for example, to ensure that no one clan, sub-district or family monopolises the financial benefit that immunization campaigns bring in wages, transport, car rental and the inevitable Kalashnikov-toting security guards.
"A disagreement over car rental can spark a serious security problem," says WHO polio co-ordinator Mohammedi Mohammed who found himself held at gunpoint last year when he refused to continue a crooked car rental deal.
But according to WHO medical officer in Mogadishu Dr Mohammed Fuji things may be changing. "We have been fighting each other for 10 years and all the world has forgotten us, " he says, "Now we are fighting polio. A lot of people are motivated now because they understand it is their children who will benefit."
Over 650 people took part in the campaign which involved going house to house or, in many cases hovel to hovel since whole areas of the city are still little more than rubble. Teams also had to seek out the internally displaced who live in birds nest-like shacks of sticks, plastic and discarded rags in over 100 camps across the city.
To reduce potential conflict, vaccinators and supervisors were selected by clan loyalty since crossing the wrong boundary can be fatal.
"In one area," says UNICEF liaison officer Discipline Mohammed, "the chief of the subsection said hed shoot any vaccinators who came because we hadnt recruited anyone from his sub district. We sat for a long time to persuade him that it was his children that would suffer."
The importance of campaign has been underlined by the discovery of at least 14 new cases of children with wild polio virus since January. Another 32 cases are under investigation. For every clinical case of polio, approximately 200 other children will be infected with the wild virus.
Carrying out polio campaigns in such war-torn places where there is no government, let alone a public health infrastructure, is controversial. Some say it is simply too dangerous, others that the coverage levels that can be achieved dont warrant the risk. But, says WHO representative to Somalia, Dr Najibullah Mojadidi, it is unethical to leave this already highly vulnerable population exposed to yet a threat to life and limb.
"Most of the remaining reservoirs of polio are in conflict zones. If we want to achieve the world-wide goal of completely eradicating this easily preventable disease, we have to find ways to reach these difficult places."
Further national immunization days are planned for August, September and October this year.
Italians focus on outbreaks
The Italian Government has donated US$430,000 to improve response to epidemic outbreaks in Somalia. Channelled though the WHO office, the funds will be used in particular to provide drugs and supplies needed to respond to the frequent outbreaks of water-born disease. Further funds are being sought to address the appalling access to clean water in most areas of the country. "This is a priority WHO keenly wants to address though funding chlorination products and helping communities develop water quality control activities," says WHO representative for Somalia, Dr Najibullah Mojadidi.
Business and behaviour blights cure Sit down for half an hour by the cholera pond in Mogadishu city and you will quickly see why trying to prevent cholera in Somalia takes persistence and patience.
Although UNICEF has dug and chlorinated two bore holes just a few hundred metres from the pond, dozens of women still sit waist deep in the murky waters washing clothes and hundreds of plastic bags which they will resell, damp and bacteria-ridden, to the food sellers in the market.
"And people still collect drinking water from the pond because its easier," says UNICEF security officer Bill Condie.
Less than 20% of Somalis have access to clean water. Not only did almost all public amenities collapsed years ago, but thousands of people live in displaced camps throughout the country with little or no sanitation.
"Even if we ensure safe water at bore holes, contamination occurs at house level," says Dr Firdosi Mehta, medical officer with WHO Somalia, who chairs the Somalia Aid Coordination Body Cholera Task Force. "Health education about personal hygiene and water protection does have an impact, but it will take 50 years to really change behaviour with the levels of poverty that exist."
In the meantime, he says, what the international community can do is target resources at reducing the number of people who die in the regular-as-clockwork November to April epidemics.
"In some areas, where there are strong NGOs, case fatality last year was as low as 1.4%. But in others where NGO people are not so capable, it reached 25.8% - thats one on four people dying of a preventable disease.
Whats needed, says Dr Mehta, is consistent donor support, firstly to allow cholera kits to be stockpiled so that treatment centres can be opened as soon as the first cases start, and secondly to train Somali and international health workers in effective management of the disease.
Last year WHO used its regular budged to support five laboratories and carried out on the job training in case management, This year, the agency hopes to carry out an entire review of cholera response using funds from the Italian Government.
All efforts in the area are, however, complicated by the fact that health is inescapably linked to business in Somalia. Opening a cholera treatment centre, for example, can come down to mini-war due to the vested interests involved in jobs, security, logistics and any part of the supplies that have market value.
Schools scan offers early care
Finding victims of leprosy before it causes lasting damage is the aim of a new partnership between International Aid Sweden and WHO in Mogadishu.
In the project, Somali nurses are being trained to screen all children in the city schools and instigate treatment for any found with leprosy, a condition which is now entirely curable.
Screening also provides an entry point for assessment and treatment of families.
Once activities are running smoothly in the capital IAS and WHO trainers plan to move onto the town of Jowhar.
The schools programme complements work being carried out by US NGO World Concern in the riverside areas of South and Central Somalia, where leprosy is endemic. This project, which has received a special US$10,000 grant from WHO headquarters, provides treatment but also sensitises health NGO workers to recognise the disease.
In a separate initiative WHOs Eastern Mediterranean office has also funded a special factory to make footware for patients who have already suffered damage from leprosy.
Mother and child health
Pay dreams harm immunization
One of the reasons that routine childhood immunization rates hover around 30% is that unrealistically high salary expectations keep the doors of mother and child units closed.
Providing a salary that will both motivate people to work and is sustainable with limited funding is difficult enough, but in Somalia it is compounded by recent history. Flush with donor funds in the immediate post war period, UNICEF and other agencies paid salaries of up to $100 a month to health workers to re-open mother and child units. But the money didnt last long and when the salaries disappeared, so did the workers.
Today, though UNICEF and various NGOs support some MCH units, most are still closed and there is still marked reluctance to work for what is seen by comparison as very low pay.
"Immunization is really suffering" says a WHO official, "The only hope is that a government comes along that can rehabilitate the primary care system enough to open the units and motivate the workers."
Somali nurse and midwife tutor Halima Abdi Sheikh, WHO national reproductive health co-ordinator, adds that women too are suffering from the dearth of mother and child care.
"The war changed many things for women. Because men are not working, women have to do a lot of work to look after food, to look after their family, and they dont look after their own health. When they are pregnant they only come to clinics in the very last stages of illness anaemic, hypertensive, pre-eclamptic, mal-nourished. And because what MCH staff there are are getting very small salaries and have few facilities, they dont take enough care of the women that do come to the clinic."
Reproductive skills need attention
WHO has appealed to the United Nations Population Fund to allocate US$1million to allow reproductive health work to continue in South and Central Somalia for a further two years.
Established in 1995, the programme has helped develop reproductive services in 43 health facilities in six regions throughout Somalia.
Key components included updating and training health workers, midwives and traditional birth assistants, providing equipment, essential drugs and health education for safe clean delivery, and raising awareness of and providing access to contraception.
Workers also encouraged activities which raised awareness of the detrimental effects of female genital mutilation which is practised on over 70% of females.
However, all activities in the area have currently ceased due to lack of funding. Even if UNFPA agree to continue funding, WHO says it will need to find further funds to extend the programme into the severely under-served areas.
Sexually transmitted disease
STD alert may help prevent HIV
Just how far the pan-African epidemic of HIV infection has permeated Somalia is hard to judge due to cultural secrecy and fragmented health services. However, recent small surveys suggest prevalence may be significantly lower than other countries in Sub Saharan countries.
A study of TB patients from centres at Hargeysa, Berbera, Boroma and Las Anod in Somaliland carried out in late 1999, for example, found prevalence ranging from 9% near the border with Ethiopia and Djibouti to 2% further inland, while another carried out UK NGO International Community Development in 2000 pregnant women in the same region found only 0.8% were HIV positive.
However, this is no reason to rest on any laurels, says WHO medical officer Dr Firdosi Mehta.
"HIV may not appear to be much of a problem now, but the ICD study also found that a third of the women complained of symptoms linked to sexually transmitted diseases which are definitely related to HIV."
Nevertheless, if the figures are accurate, Somalia could have a chance to avert the HIV epidemic not found in many African countries.
The first step, says Dr Mehta, is a two week training of trainers course due to take place in late July. Funded by UNICEF, the course will train some 30 health workers from every region in Somalia on prevention and management of STDs and how to train health workers in their own areas.
But to really implement the programme, he adds, WHO needs funds to ensure health workers will have access to a sustained supply of STD treatment drugs and barrier contraceptive methods.
Village focus but impact unknown
Ten more villages are to be added this year to 84-community basic needs development programme (BNDP) that has been a flagship project in Somalia for more than 10 years. But there are increasing requests for concrete evidence of the programmes effect.
The programme involves "sensitising" the community to their priority needs, such as clean water, food security, shelter, primary care services, education and income generation, carrying out a baseline survey of all sectors, then creating plans of action to improve them, says WHO BNDP officer Dr Said Youssouf.
One of the programme is to accelerate the development of primary care, and to facilitate this aspect WHO maintains four regional technical support teams of salaried Somalis to guide village development committees and provide training.
One of the long-standing problems of the programme, however, has been the lack of independent evaluation of whether either the sensitization process, or the action plans make any difference to health status.
According to Dr Said, the two main obstacles to evaluation have been difficulty of access and the slow development of indicators which can measure success.
For example, when an evaluation survey of quality of life progress in Lower Shebele region in 1997 could not be independently supervised because of lack of access due to insecurity, the resulting report showed unacceptably over-positive indicators.
"But basic needs development programmes are ideal for countries where there is no central administration and have proved their worth in other countries, including Jordan, Pakistan and Egypt."
It remains to be seen whether this years project managers will find a way to prove the same in Somalia.
Ph: +254 2 623 197/8/9
Fx: +254 2 520 957
Dr Najibullah Mojadidi
Dr Firdosi Mehta
Dr Said Youssouf
Natalie Van De Vyver (polio)
Technical officer: polio
Mr Mohammedi Mohammed
Health Information Systems
Ms Farah Dar
Mr Peter Arrube
Logistics and administration
Mr Frederic Caillette
This update was researched and written by Hilary Bower, information officer with the Department of Emergency and Humanitarian Action, WHO Geneva.The opinions expressed do not necessarily reflect official WHO policy. For further information, phone +41 22 791 3451, mble +41 79 249 3528 or email email@example.com or hbower26hotmail.com.