World Health Organization Organisation mondiale de la Santé

Geneva, Switzerland Genève, Suisse


Horn of Africa Initiative


11 - 23 February 2002


WHO/EHA Consultant

Addis Ababa, 22 February 2002



The Consultant was requested by WHO/EHA to provide support to the Horn of Africa Initiative (HoAI) by assessing the existing communicable diseases surveillance system in selected border districts between Ethiopia, Somaliland and Djibouti and to identify ways of enhancing the overall impact and effectiveness of the initiative. In brief the recommendations are as follows:

1. - Terms of reference for the assignment

The Consultant was requested by the WHO Emergency & Humanitarian Action Department to accomplish in the given timeframe the following mandate:

2. - Background of the HoAI

The HoAI conception dates back to a 1st Conference for Public Health in the Horn of Africa organized in April 1996 in Addis Ababa under the auspices of WHO, the Italian Govt., the ISS and the Ministry of Health of Ethiopia. The foundations of the idea to provide better services to border populations of the 7 Countries of the Horn of Africa, and hence to increase inter-Country collaboration, reduce border tensions and foster peace and development, were there initially set.

But a 2nd Regional Conference on the same theme was needed (March 1998) to reach a practical agreement between concerned authorities and decide to launch pilot activities

The Proceedings of the said 2nd Regional Conference of Public Health in the Horn of Africa, held in Addis Ababa in March 1998 – which ended with a Protocol of Agreement signed by the 7 Countries’ Health Ministers and Authorities – were never published nor circulated, as was the case for the 1st Conference of 1996, thanks to the ISS. [In the HoAI premises in Addis Ababa all documents related to the conference were found available and could be considered for publication, after minor editing and updating].

The Initiative started with the posting of an International Co-ordinator: in the timeframe of his assignment (June 1998 – May 2000) Dr C. Forni performed a number of activities ranging from assessing the health situation in selected areas, to providing some equipment to most deprived health facilities, to organising short training/refresher courses for health personnel. Unfortunately, due to the exclusive dependence on the Italian funding and the lack of broad promotion of the HoAI, the project activities were discontinued after the departure of the expert. They were resumed with the nomination of a new International Co-ordinator in October 2001 (Dr Abdullahi Ahmed), the same who is performing a formidable work: round of visits, networking, linking with national and international partners, promoting the "one WHO" concept, aiming at sustainability of action.

As an additional asset, in the period May-August 2001 a Protocol of Co-operation was signed between the 2 WHO Regional Offices concerned and the IGAD, setting the foundation for the political backstopping of the initiative.

3. - Prior-to-travel activities at Geneva/HQs

On instruction of the desk officer Dr Lianne Kuppens, the Consultant met on 8 Febr Dr O. Adams, Director OSD, and his assistant Dr Hedwig Goede, since OSD is interested in cross-border inter-Country health collaboration activities.

They were wondering about the population size and the magnitude of the health problems, having in mind similar strategies for some EURO Member States. Nothing in place yet, but keeping communication channels across the house open could result in mutual benefit to both EHA and OSD Departments.

As for EWARN, contacts with CSR failed due to unavailability of people, still the consultant obtained and examined recent reports of similar activities successfully implemented by CSR in conflict-torn areas in south-Sudan (WER no. 4, 25 Jan 2002).

4. - Field trips

Two field trips were undertaken, both inside the Somali National Regional State (SNRS), which is the easternmost Region of Ethiopia, bordering Somaliland and Djibouti [see map at the end of this report]. The capital is Jijiga, 628 km from Addis Ababa, where the Regional Health Bureau (RHB) is based. The region embraces 9 Zones, each with a Zonal Health Department (ZHD). The premises of the Shinile ZHD, to which districts bordering Djibouti belong, are located in Dire Dawa (520 km from A.A.).

The field trips were conducted along the following routes:

Details on both visits are provided in Annex. As a common feature, those districts show how the health systems of bordering Countries are stronger than the Ethiopian one at peripheral level, therefore extending services to Ethiopian patients in different occasions: in particular, patients from the Aysha districts are often referred to the Ali Sabieh hospital in Djibouti.

5. - Assessment of the existing Surveillance system

The surveillance system is mainly based on passive case detection (PCD) and reporting through the standard form implemented nation-wide [see attachment].

17 diseases are subject to surveillance, namely:

There is no feed-back from centre to periphery about accurateness/coherence of reporting and even the Supervision is weak and conducted haphazardly and on ad-hoc basis (e.g. the head of ZHD seized the opportunity of accompanying the mission to perform supervision of health facilities along the route). The justification – reportedly – is the lack of means coupled with lack of an agreed upon supervision plan and schedule. A plan for standardising supervision is being developed indeed in the frame of the support from the Austrian Govt. to the SNRS [see attachment].

HoAI should link with these commendable initiatives.

The early warning system already in place is extremely poor and strongly based on community’s traditional mechanisms of solidarity: religious and community leaders – with sporadic support from few Community Health Agents and Traditional Birth Attendants – alert neighbours of any unexpected/threatening event affecting the health of people (e.g. bloody diarrhoea reported at the time of the visit in remote communities, currently under clinical & lab investigation). An individual-to-individual oral chain is then activated, which can reach health staff in one day or more, up to weeks.

The HS, in turn, is unable to perform outreach activities due to critical shortage of means, in particular:

6. - The Ethiopian Health Sector Development Programme – HSDP

The Ethiopian Health Sector Development Programme (HSDP) is a comprehensive plan of sectoral development launched in close partnership between the Ethiopian Government (MEDAC, MoH, Regions) and the international aid community in the mid-nineties: it encompasses an innovative approach to national long-term planning in prioritised social sectors (health, education etc.) as well as international co-operation for support to health services development. The rationale behind such strategy was based on the Sector-wide Approach (SWAp) to health sector development and stems from the Sector Investment Programmes of the World Bank tailored to poorest Countries.

The exercise started, shortly after Ethiopia regained the status of democracy in the early nineties, from the Social Sector Review launched by the European Community and the following exercise of Co-ordination between the EC and the EU Member States in selected Countries (among which Ethiopia) and in priority sectors (among which Health).

The EC, major bilateral donors and the World Bank joined efforts to pool resources towards institutional capacity building while defining common rules on an agreed-upon comprehensive plan – on the mid-term – to deliver support to the health sector. The HSDP is currently heading towards the completion of the first 5-year plan which considered a total expenditure of about 5 Million Eth. Birr (equivalent to about 720 million US$), out of which 60 % covered by national budget, 100M US$ by a IBRD soft-loan and the rest pledged by donors as grant entitlement.

The HSDP considers three possible channels of external support:

  1. Budget support channelled through the Ministry of Finance -> MoH -> Regions;
  2. Programme support channelled directly to the MoH then ->Regions;
  3. Project support directed to the beneficiary at peripheral level, be it at Zones, Woredas or Health facilities level.

The relevancy of the HSDP to the HoAI stays in the fact that, in the whole Plan some Regions were unanimously considered weakest and in need for heaviest support, i.e. the Somali and Afar regions and, inside those, especially vulnerable groups – like pastoralist nomads, cross-border migrants, internally displaced groups etc. – should be given the outmost attention.

To some extent, HSDP and HoAI share similar concerns for border districts, and some stakeholders in the donor community expressed interest in providing support to them (the Austrian and Italian Govts., the EC and some NGOs among others).

Finally, close collaboration should be pursued between the HoAI and HSDP in order to secure sustainable support to border district health activities and – hence – to attain the ultimate goal of the Initiative itself of improving the health status of border populations. Worth to be recalled as an asset, the HoAI focal point in the SNRS-RHB, Mr Abdirahman M. Aden (head of Planning) is the same who worked to the Somali Regional Health Plan since its inception.

7. - Proposal for an Early Warning System

HoAI - in close collaboration with MoH/HSDP - should undertake the following steps, in order:

  1. Conducting an operational research on health patterns of nomadic/pastoralist lifestyle, major health needs and appropriate delivery of health services; the draft Terms of Reference for such investigation were provided to the consultant by the HoAI focal point in Jijiga-RHB. Worth recalling that Mr Abdirahman holds a MPH degree from Boston University and is especially keen of operational research in remote and difficult settings. [The 1st draft Proposal and ToR for the research is annexed, its costs result negligible].
  2. Concentrating activities and support on few (3 to 4 max) border areas of Ethiopia with neighbouring Countries, as pilot areas to build partnership and test successful methods and strategies to be replicated elsewhere and incorporated into national health plans. Ethiopian HSDP is already considering such activities as for the Somali and Afar Regions.
  3. Consolidating Cross-Border Health Committees, as the key tool for health activities: the next meeting for the newly nominated CBHCs is scheduled for the coming 1st week of March in Dire Dawa. In any case, first established CBHCs across the HoAI should be ready by the end of 1st quarter of 2002.
  4. Enforcing the foundations of an Early Warning System in the said areas by providing minimal transportation [motorcycles] and communication [VHF radio equipment] means, delivering basic tools for first handling of epidemics and training of community leaders – and possibly CHAs and TBAs – on early detection of potential outbreak’s risks.

The basic elements of such an EWARN are summarized here below, assuming as an example the visited area:

Table 1: Elements of EWARN for the Ethiopia-Djibouti-Somaliland border areas



unit cost US$

total cost


Motorcycles (e.g. Yamaha 175 cc)




VHF complete radio equipment




Basic toolkit for a health station




Training/refresher module for CHAs & TBAs in SNRS

30 people



Logistics and overheads



Grand Total US$



8. - Additional recommendations


The mission was made possible and facilitated by Dr Alessandro Loretti (EHA/EHC Coordinator) and Dr Lianne Kuppens (HoAI desk officer at HQs). The HoAI Coordinator in A.A., Dr Abdullahi Ahmed, was extremely supportive and helpful despite his very busy schedule.

Thanks are also due to his staff, namely: Ms Kwelemwork Tesfa, assistant, Ms Tsehay and Mr Yonas Beidemariam, driver, excellent companion for the field trips.

In the WRO I am duly acknowledging the orientation and advice from Dr Michel Jancloes, EXD/WR Ethiopia, the support from the Administrator and staff and from Mr Mulugeta Gebru, EHA focal point.

Dr Fathi Dahir (Dir. CD Prev & Control) and Mr Abdirahman Adan (Dir. Planning) provided invaluable support at RHB, as well as Mr Adawe, Head of ZHD of the SNRS.

Committed professionals of the Somali Region accompanied all the time the field visits.



(for ease of consultation, only front pages are annexed; complete documents are available on request at EHA and HoAI offices)


  1. Map of the Somali National regional State (SNRS) + woredas
  2. Map of the Shinile zone
  3. Map of the Ethiopian - Somalia borders
  4. Operational Research Proposal in 3 border district, draft by Abdirahman Adan (2002)
  5. AFP/Polio Surveillance Guidelines, by FDRE/MoH
  6. Polio eradication leaflet (in Somali language)
  7. List of basic drugs stockpiling at health facility level
  8. Integrated Supervision Checklist, by RHB/SNRS
  9. Forms:

  10. Epidemic Disease reporting/ by health facility
  11. CD Surveillance report form/ national
  12. Mother & Child health care/ by RHB/SNRS
  13. Leaflet of the 2nd Regional Conference of Public Health in the Horn of Africa (March 1998)

Courtesy of Mr Abdirahman M. Aden – Head of Planning Dept., Regional Health Bureau, Somali National Regional State, ETHIOPIA