By Sahra Noor
Over four decades of civil war, extreme poverty, and political instability have made Somalia’s health system, one of Africa’s most fragile systems. The COVID-19 crisis and numerous health system strategic planning and analysis documents reveal significant gaps in the country’s health infrastructure and emergency response and preparedness capacity. Yet, most funds from international donors go to a hotchpotch of loosely coordinated projects and programs that address short term needs but are not well aligned with the national development priorities or significantly improve health outcomes.
It’s prudent now more than ever to strategically invest the COVID-19 response funds to rebuild a sustainable health system with national institutions that can meet current needs and withstand future outbreaks and pandemics.
The State of COVID-19 in Somalia
Somalia reported its first case of COVID-19 on March 16, 2020. Since then, there have been 4,579 infections and 121confirmed deaths as of December 12, 2020[1]. While the infection and death rates are lower than forecasted, the COVID-19 pandemic came against the backdrop of humanitarian crises caused by devastating desert locusts and floods.
In addition, to the millions of dollars already budgeted for health in 2020, the Somalia Humanitarian Fund (SHF)[2] reported that as of October 25, 2020, the country received only thirty percent of the budgeted U$256 million to implement the COVID-19 Strategic Preparedness and Response Plan (CPRP). The funds allocated for health response that are yet to be received ought to be deployed towards institutional building and a whole system approach to population health improvement that will transform the health system.
However, based on my experience consulting on Somali health care projects, this will not be easy. Coalescing donor partners and stakeholders around a vision that will ultimately lead to sustainable change require bold leadership and political will.
So, how do we invest the funds in a way that achieves a more significant impact?
Build institutions that fill systemic gaps
The funds can be used to fully operationalize the nascent National Institute of Health (NIH)[3], so it has the leadership and governance structure to coordinate health emergency preparedness and response efforts. Significant investments can be directed towards expanding the National Public Health Reference Laboratories (NPHRL) and blood banks to improve diagnostic tools and access to safe blood supply. We can accelerate the implementation of Universal Health Coverage, so life-saving primary health care, vaccines, and medicines are accessible and affordable to women, children, and those most vulnerable in society. Establishing a functional national authority that enacts and enforces health care policies and laws will keep millions of Somalis safe from the harm caused by unregulated drugs, devices, and vaccines.
Adapt and scale COVID-19 related to public health initiatives
The funds are currently used to improve access to COVID-19 testing, tracing, and treatment capacity and train thousands of front-line health workers. Increased community outreach projects that promote infection control messages and increase access to clean water, sanitation, and hygiene (WASH) services have also helped reduce infections and save lives during this pandemic.
In a country where more than sixty percent of the population do not have access to WASH services, culturally relevant health promotion messages, and primary health care, these initiatives are prudent emergency interventions. However, when institutionalized and scaled up, they can gradually shift the public’s attitude and behaviors towards prevention and health promotion, which reduce the risk of infections and the need for costly hospitalizations and treatment.
Sustain community and stakeholder engagement and mobilization
From the beginning of the pandemic, the global Somali community has joined forces to advocate, mobilize resources, and respond in unprecedented ways. Health care experts, civil society organizations, and religious leaders in the country and across the diaspora organized fundraising, scheduled virtual training, donated equipment and supplies, and produced educational materials and messages. COVID-19 is likely to persist in the foreseeable future, necessitating continued engagement and mobilization.
Collaboration, knowledge sharing, and resource mobilization among government(s) and stakeholders, including health practitioners, healthcare entrepreneurs, diaspora groups, civil society, advocates, donors, and NGOs, is crucial to rebuilding the health system. As Somalis say, “far kaliya fool ma dhaqdo.”
Build transparent and accountable financial systems
Pandemic-related global solidarity and increased public health funding come with a greater need for financial transparency and accountability.
It’s estimated that the domestic budget allocation for health care is less than 5%. This means that over 90% of health programs and projects depend on donor funding, which does not bode well for the country’s continued health system strengthening efforts. Most international donors also directly fund UN agencies or NGOs to provide health services, limiting the government’s ability to lead and influence systemic change.[4]
The direct donor-to-provider funding processes undercut the government’s ownership and impede a systematic approach to problem-solving and implementation, making it challenging to have a line of sight on the gaps between what is needed and what is funded, let alone how it’s managed. Strengthening the government’s capacity to plan and deliver health care means they could charge administrative fees and use it to build their fund management, procurement systems, health policies, and pay for their staff.
Unfortunately, recent reports of corruption and misuse of funds by health officials[5] derail these efforts and deepen concerns about the government’s ability and willingness to prioritize population health above all else and enact new measures to address corruption and embezzlement donor funds. The Public Resource Management in Somalia, PREMIS[6], and the Word Bank funded Damaal Caafimaad are two promising projects that serve as a pathway to full accountability and transparency. The extent to which they curb corruption and engender trust among donors and the public is yet to be seen.
The adage of “don’t let a crisis go to waste” applies to the Somali context as the country needs to address immediate socio-economic challenges of the pandemic and long-term gaps in the health care system. The Health system’s resilience and sustainability beyond the COVID-19 ought to be a priority for Somalia’s government, health providers, donor agencies, and advocates.
Will the Somali leadership seize this opportunity to direct COVID-19 funding to institutional building and strengthening, or will they keep the current status quo by maintaining a perpetually weak and fragmented health system?
Sahra Noor
Email: [email protected]
Sahra is an award-winning healthcare executive and founder of Grit Partners Consulting
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[1] https://www.who.int/countries/som/
[2]https://reliefweb.int/report/somalia/somalia-humanitarian-funding-overview-data-03-september-2019
[3] https://nih.gov.so/
[4] https://www.odi.org/blogs/17411-beyond-pandemic-strengthening-somalia-s-health-system
[5] https://nationaltelegraph.net/top-somali-health-officials-arrested-over-covid-19-money/
[6] https://mof.gov.so/pfm
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