S O M A L I A - Unicef

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Ê-/1/" Ê  9--Ê"Ê , *," 1 /6  /Ê April 2009

This document has beeen produced upon request and with collaboration of the health authorities of Somalia. This document has been developed with assistance from UNFPA, WHO and UNICEF. The views expressed herein cannot be taken to reflect the official opinion of UNFPA, WHO or UNICEF.

Ê-/1/" Ê 9-"Ê, *," 1 /6 Ê /Ê  Ê-"Ê April 2009 Ingvil Krarup Sorbye, MD Consultant WHO/UNFPA Somalia offices

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Table of Contents Acknowledgements. Abbreviations. .

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7 8

Executive summary.

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10

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1.

Introduction and methodology.

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1.1 1.2 1.3 1.4 1.5

Reproductive health rights. . . . Background: Somalia. . . . Reproductive health in a Somali cultural context. Reproductive health indicators for Somalia. Methodology. . . . . .

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15 18 21 23 28

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Service delivery. .

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2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 2.10 2.11 2.12 2.13 2.14 2.15

Health systems, infrastructure and service delivery. Proposed framework for delivery of health services. General barriers to access. . . . . Quality of services. . . . . . Safety . . . . . . . Essential delivery care. . . . . Emergency Obstetric Care (EmOC). . . . Neonatal and postnatal care. . . . Antenatal care. . . . . . Postpartum care. . . . . . Family planning/birth spacing. . . . Obstetric Fistula . . . . . . Post-abortion care. . . . . . Prevention and treatment of STI/HIV-AIDS. . Medical response to survivors of sexual & gender-based violence (SGBV). . . . Adolescent and youth reproductive health. . . Infertility and cancer of the reproductive tract organs.

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32 34 36 36 36 37 43 51 53 58 60 63 65 66

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67 69 70

3.

Health work force.

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72

3.1 3.2 3.3 3.4

HR policy level. . . . . HR availability and production. . . Key human resource issues and concerns. . HR management. . . . .

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72 72 75 77

4.

Information.

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78

4.1

Health information systems. .

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78

5.

Finances.

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79

5.1 5.2 5.3

Healthcare finance and expenditure. . . Payment of RH services. . . . . Future financing of reproductive health services. .

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79 81 82

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Medical products and technologies.

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85

6.1

RH commodity supply and distribution.

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85

2.16 2.17

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7.

Governance.

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86

7.1

Governance in RH.

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86

8.

Discussion. .

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87

8.1 8.2 8.3

Addressing maternal and neonatal survival. . . Bridging the gaps. . . . . . . Community mobilization for reproductive health services.

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87 88 89

9.

Summary of conclusions and recommendations.

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90

9.1 9.2 9.3 9.4.

Essential and Emergency Obstetric Care. . . Antenatal, postpartum and neonatal care. . . Birth spacing/limiting and prevention of pregnancy. Obstetric fistula, post-abortion care and sexual- and gender-based violence, including FGM. . . Human resources, finances and governance. .

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90 90 91

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91 92

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9.5

REFERENCES. ANNEX A: ANNEX B: ANNEX C: ANNEX D: ANNEX ANNEX ANNEX ANNEX ANNEX ANNEX ANNEX ANNEX ANNEX

E: F: G: H: I: J: K: L: M:

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WHO shortlist of Reproductive Health Indicators for Global Monitoring. . . . . . . Institutions and persons visited in Hargeisa, 02/09. . Basic and Comprehensive Obstetric Care. . . . Monitoring and evaluation tools of obstetric and neonatal care: UN process indicators. . . . . . ([FHUSWVIURP³7KH(VVHQWLDO3DFNDJHRI+HDOWK6HUYLFHV´. Obstetric care Somaliland: information as at January 2009. Obstetric care in Puntland: information as at January 2009 . Obstetric care in Central South Zone as at January 2009. Reproductive health activities by implementing partners. . SGBV/FGM: Lessons learned and best practices . . . Organizational structure of the Ministry of Health(3 zones). Maternity waiting shelters. . . . . . Terms of Reference - Consultant Reproductive Health. .

96 98 99 100 101 109 111 112 114 121 122 125 126

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Acknowledgements The people and organizations below are acknowledged for their contributions at various stages of this work. -

Somalia Support Secretariat, Nairobi (Including Dr Kamran Mashhadi) Dr. Marthe Everard WHO Somalia Dr. Humayun Rizwan WHO Somalia Mr. George Nsiah UNFPA Somalia Dr. Rogaia Abuelgasim UNFPA Somalia Dr. Suraya Dalil UNICEF Somalia Austen Davis UNICEF Somalia Dr Geoffrey Acaye UNICEF Somalia

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Officers Officers Officers & Consultants

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Ministry of Health and Labour, Somaliland Somaliland Medical Association Somaliland Nurse and Midwife Association Staff and Director, Hargeisa Group Hospital, Hargeisa Staff and Director, Edna Adan Maternity Hospital, Hargeisa Staff and Director, Manhall Hospital, Hargeisa

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AAH CCBRS COOPI CISP COSV CRS GHC Health Unlimited IMC ICRC/IFRC/SRCS LATH MDM MSF H MSF B MSF CH MSF ES Muslim Aid SC/UK SOS Kinderdorf THET

WHO Somalia/Nairobi/Hargeisa/Garowe UNFPA Somalia/Nairobi/Hargeisa/Garowe UNICEF Somalia/Nairobi/Hargeisa/ Garowe/Bosasso

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Abbreviations AIDS ANC APH ART BCC BEmOC CDK CEmOC CFR CHW CISP COOPI COSV CPR CS CSZ EOC EPHS FGM FP FSAU GHC H HBV HC HGH HIV HMIS HPV HR IASC IBP ICRC IDP IFRC IMC IUFD IUD KABP KAP

acquired immune deficiency syndrome antenatal care ante-partum haemorrhage antiretroviral therapy behaviour change communication basic emergency obstetric care clean delivery kit comprehensive emergency obstetric care case fatality rate community health worker Comitato Internazionale Cooperazione Internazionale per lo Sviluppo Dei Popoli Comitato Di Coordinamento Delle Organizzazioni Per Il Servizio Volontario contraceptive prevalence rate Caesarean section Central South Zone emergency obstetric care Essential Package of Health Services female genital mutilation family planning Food Security Analysis Unit Gedo Health Consortium hospital hepatitis B virus health centre Hargeisa Group Hospital human immunodeficiency virus health management information system human papilloma virus human resources Inter-Agency Standing Committee Implementing Best Practices International Committee of Red Cross internally displaced person International Federation of Red Cross and Red Crescent Societies International Medical Corps intrauterine foetal death intrauterine contraceptive device knowledge, attitudes, behaviour, practices knowledge, attitudes and practices

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MCH MD MDM MDG M&E MICS MMR MoH MoHL MSF NEZ NGO NWZ OPD OT PAM PEP PMR PMTCT PNC PPC PPH RH RPR SC/UK SGBV SRCS STI TB TBA TFG TFR TPHA TT UN UNAIDS UNDP UNFPA UNICEF UTI VCT VDRL WHO

mother and child health medical doctor Médecins du Monde Millennium Development Goal monitoring and evaluation Multiple Indicator Cluster Survey maternal mortality ratio Ministry of Health Ministry of Health and Labour Médecins Sans Frontieres North East Zone non-governmental organization North West Zone outpatient department operation theatre pregnancy-associated malaria post-exposure prophylaxis perinatal mortality rate prevention of mother to child transmission postnatal care postpartum care postpartum haemorrhage reproductive health rapid plasma reagin Save the Children - United Kingdom sexual and gender-based violence Somali Red Crescent Society sexually transmitted infection tuberculosis traditional birth attendant Transitional Federal Government total fertility rate Treponema Pallidum Haemagglutination Assay tetanus toxoid United Nations Joint United Nations Programme on HIV/AIDS United Nations Development Programme United Nations Population Fund United Nations &KLOGUHQ¶V¶ Fund urinary tract infection voluntary counselling and testing venereal disease research laboratory World Health Organization

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Executive summary Background Reproductive health implies that people are able to have a responsible, satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so. In Somalia, the reality within reproductive health is far from this goal. Indicators show high maternal and perinatal mortality, a very high fertility rate and almost universal female genital mutilation. Poverty, low status of women, suboptimal nutritional status and widespread additional harmful practices further contribute to the high burden of ill-health among mothers and newborns. Due to poor basic education and lack of sexual education in schools, levels of information on risks related to pregnancy and childbirth are low, and are more likely to derive from traditional beliefs than from informed health staff. Awareness of beneficial effects of preventive health services such as vaccination and birth spacing is poor and many misconceptions prevail.

Rationale for the study A comprehensive situation analysis of reproductive health in Somalia at this point in time was identified from the need for relevant background information in order to be able to assess needs, gaps and possibilities for intervention. Based on this, the plan is to formulate a prioritized action strategy in a setting where needs are widespread and restraints concerning access to population, security and financial means are many.

Methodology The core findings of this report are based on an extensive literature review, interviews with key implementing actors at field and headquarter levels. Restrictions on access to Somalia due to poor security made it necessary to conduct the majority of the work from Nairobi (Kenya) and Hargeisa (Somaliland).

Key findings There are considerable unmet needs in all major fields of reproductive health in Somalia. Due to years of war, conflict and lack of an effective government, the health system is fragmented, highly privatized and underperforming, and suffers from major deficiencies in basic funding, qualified human resources and management mechanisms. Concerning maternal and neonatal health, more than 90% of women deliver at home and more than half are assisted by a traditional birth attendant. Access to skilled delivery care and emergency obstetric care is poor, and the

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rural and nomadic populations are virtually without access to timely obstetric intervention should the need arise. There is a major lack of facilities able to handle basic emergency obstetric care, and a dire shortage of qualified midwives to staff and manage these. Referral centres for caesarean sections are under-utilized and the services are of poor quality with a high case fatality rate. Newborn care is neglected, with major missed opportunities to secure immediate survival. Only one out of four pregnant women attends antenatal care where services are of poor quality, constituting another missed opportunity. Concerning birth spacing and limiting, 26% of women have unmet needs yet only 1% of Somali women uses a modern method of family planning. Postabortion care and medical treatment for victims of sexual and gender-based violence and STIs are not universally available. The special needs of adolescents are presently not being addressed. Barriers to accessing reproductive health care are many: low awareness among the population of beneficial effects; financial obstacles in the form of almost universal user fees and expensive transport; logistic obstacles such as long distances and lack of transport to health service providers for rural and nomadic populations, all play a part. Poor quality of services, a high number of unskilled staff, incoherent running of services and breaks in supplies, harm trust in the public sector and further aggravate the situation. The present pool of qualified reproductive health staff is small, aged and under-trained, with a grave shortage of qualified midwives. Urban clustering of qualified midwives and doctors leaves rural areas relying heavily on auxiliary staff, most of who are inadequately trained for their job. Doctors are presently graduating in small numbers, whilst midwifery education is ongoing only in one zone, on a small scale. Few systems are in place for enforced deployment of new staff within the public system, and there are few effective mechanisms for motivation and retention, especially for the rural or difficult-to-reach areas. Reproductive health financing has been neglected for many years. The current trend of vertical programs does not favour maternal health programs due to the need for a health system approach. Innovative service financing mechanisms are sorely needed to replace the present system of major outof-pocket payments for reproductive health services, which seriously hamper access, performance and utilization. There is a weak basis for governance, with weak structures and political will. As a result, projects are donor or NGO-driven and in many cases demonstrate a random approach to reproductive health rather than coordinating and aligning their programs according to strategy and needs.

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Conclusions and recommendations Looking at core findings and conclusions of this analysis alongside the recommendations of consultative workshops held in Nairobi and Somalia with different UN, NGO and Somali medical staff, we can define the following areas for action in order to ensure appreciable progress. 1. Essential and emergency obstetric care Skilled attendance at birth is the ultimate goal Dramatically increase the number of midwives for the public sector by up-scaling post-basic midwifery and community midwifery pre-service training in all three zones, linked to mechanisms for deployment, motivation and retention Increase number of professionals able to practice obstetric surgery by establishing 3-6 months in-service training in Emergency Obstetric Care for newly graduating doctors Comprehensive refresher EmOC in-service training for all doctors and midwives Increase access to EmOC by upgrading existing MCHs to health centres able to provide Basic Emergency Obstetric Care, within referral distance of a facility offering Comprehensive Emergency Obstetric Services and appropriate referral mechanisms Initiate maternity waiting shelters to improve access for rural and nomadic populations to Emergency Obstetric Care Ensure affordable services by free referral vouchers for major obstetric interventions and facility-based births Intermediate-term measures to assure skilled attendance at home births such as scaling up training of community midwives Explore innovative practices such as incentivized referral and new roles for unskilled staff, such as a role in newborn care and recruitment into other cadres such as the CHW Classic traditional birth attendant training in safe delivery to be phased out. Due to the gap in skilled care at delivery to be expected during the intermediate period, strategies to bridge the gaps whilst waiting for output of human resources must remain. In areas where skilled care is unavailable, the role of the TBA will be transformed to one of prepartum referral to facility-based care, a role in newborn care and possibly in piloting community-based distribution of new RH technologies, such as Misoprostol to prevent postpartum haemorrhage. Exploration of innovative practices such as incentivized referral and recruitment into other cadres, such as CHW.

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2. Antenatal, postpartum and neonatal care Addressing underutilisation of public sector health staff, paying realistic salaries according to an accepted scale, expanding opening hours at health centres and improving performance Explore performance-based financing and incentives Improved supply chain with revised kits and shared logistics between partners Scale up in-service training capacity, with a focus on major gaps Adapted and updated protocols and guidelines in place Improve quality and comprehensiveness of antenatal and neonatal care by addressing missed opportunities Explore innovative practices such as incentivized referral and new roles for unskilled staff, among them TBAs, such as a role in newborn care and recruitment into other cadres such as the CHW Integrate prevention of STI and HIV-AIDS at health centre level Ensure increased community demand for services by reinventing the role of the community health worker to one of a trained, paid, extended arm of the health centre 3. Birth spacing/child limiting and prevention of pregnancy Universal affordable access to and choice of a reasonable mix of contraceptive methods at each level of health facilities Addressing training needs of health staff Introducing national guidelines as well as protocols for facilities Early involvement of men and key community actors, including religious leaders, for programmatic sanction Expanding demand by extensive behaviour change communication through community health workers and health facilities emphasizing the positive health benefits of birth spacing 4. Obstetric fistula, post-abortion care and sexual and gender-based violence including FGM Prevention a priority by increasing access to quality Emergency Obstetric Care services Prepartum referral to waiting shelter for primiparas in rural and nomadic areas Adequate family planning program to delay first pregnancy beyond early adolescence Increased access to and quality of health services, and commodities for comprehensive management of post-abortion care, fistula, sexual

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and gender-based violence including complications of female genital mutilation (FGM) Increase awareness among decision-makers in the community, of the harmful effects of FGM 5. Human resources, finances and governance Scaling up graduation of quality post-basic and community midwives in all three zones Recruit new doctors to in-service emergency obstetric care training Ensure more equitable coverage of rural and underserved areas, by recruitment from such areas linked to deployment and commitment to placement for a defined time period, with adequate reimbursement and career opportunities Innovative and sustainable RH financing mechanisms necessary Explore performance-based financing to increase output and efficiency of existing facilities and health staff Establish reproductive health national policies and develop strategies for each zone Establish governance structures and consortiums to ensure national programme ownership Improved interagency collaboration, coordination and convergence of RH services at all levels. Way forward This document is an element of a planned consultative process with all stakeholders and partners to ensure a concerted, coherent future effective approach to reproductive health by agreement on a National Policy and consequent Strategy for Somalia, leading to development of a prioritized Plan of Action.

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1.

Introduction and methodology

Poverty, low levels of female literacy and lack of female empowerment are factors that correlate strongly to poor reproductive health outcomes in different countries. In Somalia, matters have been worsened by chronic war and conflict over almost two decades, lack of a functional central government, and poor access to quality reproductive health services. Despite increases in knowledge of HIIHFWLYHPHDVXUHVDQG³ZKDWZRUNV´ in reproductive health, progress in maternal health towards MDG 5 is not on track. The majority of deaths and disability among females of reproductive age is related to pregnancy and childbirth. Optimal pregnancy care depends on all levels of the health system, from basic preventive services such as vaccination and birth spacing services, to highly technical emergency obstetric care at referral level. Assuring support to maternal survival requires an approach different to that for child survival, in which major improvements can be made with low cost technology at the community level. Good obstetric care is thus crucially dependent on a well-functioning, interlinked health care system at all levels. This is non-existent in Somalia today. Firstly, securing reproductive health will require a focused, consistent, longterm effort to strengthen health systems. Any ³PDJLFEXOOHW´RUVLQJOH intervention is unlikely to produce desired results, and might function as a detour rather than a shortcut to maternal health (Maine, 2007). Secondly, there is a constraint in Somalia where access to the population is restricted. There is thus an urgent obligation to focus on what is possible and effective in improving maternal survival within the current situation, using current knowledge and best practices in order to formulate a prioritized and focused plan of action. In this report issues of poverty, female literacy and empowerment as important determinants of reproductive health within the general area of interest, but the focus is centred around PHGLFDODVSHFWVRIZRPHQ¶V reproductive health and events during ZRPHQ¶Vreproductive ages between 15 and 49 years that can be dealt with or improved by effective health systems.

1.1

Reproductive health rights

The securing of reproductive health (RH) rights is a relatively new agenda, with the first international resolution to mention reproductive health rights emerging in 1994 at the International Conference of Population and Development, in Cairo. More specifically, reproductive health (according to WHO) is the right of men and women to be informed of and to have access to safe, effective, affordable and acceptable methods of fertility regulation of

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their choice, and the right of access to appropriate health care services that will enable women to pass safely through pregnancy and childbirth, and provide couples with the best chance of having a healthy infant.

Box 1.1 ³Reproductive health implies that people are able to have a responsible, satisfying and safe sex life and that they have the capability to reproduce DQGWKHIUHHGRPWRGHFLGHLIZKHQDQGKRZRIWHQWRGRVR´ (WHO website, 2008).

In most countries reproductive health rights are still in the process of being secured, ranging from fulfilment of most rights in some countries and a mere utopia for others. The major elements of reproductive health focused on in this report are: Essential delivery care/skilled attendance at birth Emergency Obstetric Care Neonatal and Postnatal Care Antenatal Care Postpartum Care Family planning/birth spacing Obstetric fistula Post-abortion care Prevention and treatment of STIs/HIV-AIDS Medical response to survivors of sexual and gender-based violence, including FGM Adolescent sexual and reproductive health and rights Infertility and cancer of the reproductive organs Actions addressing female empowerment, gender equality and female education are considered beyond the general scope of this document, but will be dealt with where relevant for health programming. 1.1.1

Evidence-based practices: What works for maternal and newborn survival?

There is general agreement among members of the international Safe Motherhood community, as well as most global maternal health initiatives, that knowledge on what works for maternal survival is already established. The challenge that remains is to put knowledge into practice, and scaling up already effective interventions. Cost-effectiveness is documented for a number of interventions in East Africa (Box 1.2).

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Box 1.2 Selected cost-effective interventions for maternal and neonatal care for the East African region (Taghreed et al, 2005). TT - vaccination Nutritional supplementation for undernourished pregnant and lactating women Community-based neonatal care package Screening and treatment for preeclampsia Screening and treatment for asymptomatic bacteriuria Screening and treatment for syphilis Skilled maternal care and immediate care of the newborn Management of obstructed labour, breech presentation and foetal distress Steroids for preterm birth Management of maternal sepsis Antibiotics for premature preterm rupture of membranes Referral for postpartum haemorrhage

There is general agreement that three elements are important for reducing maternal and neonatal deaths: 1) Reduce numbers of pregnancies and unsafe abortions 2) Reduce incidence of pregnancy complications 3) Treat pregnancy complications in a timely and optimal manner 1) Reduce numbers of unwanted pregnancies and unsafe abortions Reducing the number of pregnancies that women have during their lifetimes substantially reduces their risks of maternal mortality and morbidity, particularly where fertility rates are high and health facilities are poor or unavailable1. Concerning child survival, couples can reduce their FKLOGUHQ¶V¶ health risks by spacing births. Children born within 17 months after the preceding birth are about twice as likely to die before the age of five as those born 24 to 47 months after the preceding child. The risk of dying decreases with increasing birth interval lengths up to 36 months, at which point the risk plateaus (Rutstein, 2005). Birth spacing does not seems to have a net positive effect on maternal health other than reduced overall fecundity. A net positive effect of the benefits of 1 The study in Matlab, Bangladesh, illustrates how fewer pregnancies results in fewer maternal deaths. In 1977 more intensive family planning services, including home visits by trained female family planning workers, were introduced in selected villages. In these test villages the percentage of married women using contraception rose from 8% in 1976 to almost 40% by 1985. In comparison areas where services were not expanded, the rate rose much less, (5% to 17%.) By the end of the study maternal mortality in the test villages had fallen to less than half that in the comparison villages, even though there was no change in the risk of dying from any one pregnancy.

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birth spacing on maternal health is controversial, as both long and short pregnancy intervals are associated with increased risks of certain conditions (Conde-Agudelo, 2007; Ronsmans, 1998). 2) Reduce incidence of pregnancy complications Primary prevention is achieved by optimized care during pregnancy and delivery. This includes optimized pre-pregnant health status; four focused antenatal care visits2, skilled assistance at delivery and avoidance of harmful practices. 3) Treat pregnancy complications for mother and baby in a timely and optimal manner Physiologically, about 15% of pregnant women worldwide develop a potentially life-threatening complication that calls for skilled care; about 5% will require a major obstetric intervention for maternal or neonatal survival. Most obstetric complications can neither be predicted3 nor prevented, but if women receive effective treatment in time almost all can be saved. This requires timely access to emergency obstetric care for all women. Early newborn survival depends on the above elements. An estimated 3045% of newborn and intrapartum stillbirths can be averted through good obstetric care (Lawn et al, 1983). In addition to initial newborn care4 such as thermal protection, resuscitation, care of the preterm and early exclusive breastfeeding, avoidance of harmful practices are important. 1.1.2

Rationale for the study

The purpose of conducting a comprehensive situation analysis of reproductive health in Somalia at this point of time, was the identified need for background information to be able to assess needs, gaps and possibilities for intervention. Based on this, a coherent future approach to reproductive health in the form of a national strategy can be developed, as well a plan of concerted prioritized action for all actors in Somalia.

1.2

Background: Somalia

Somalia has been without an effective central government since the overthrow of President Siad Barre in 1991. EvHQLQWKH¶VGXULQJKLV regime, access to primary health care for the rural population was recorded as between 6-ZKLFKLVGLVPDOO\ORZDQGORZHUWKDQWRGD\¶VQXPEHUV 2 WHO recommends four focused antenatal visits. The same scale is considered in the MDG five monitoring indicators. 3 Screening of women according to their medical and reproductive history is not effective in identifying all those who will develop complications, as most women in the high-risk groups deliver normally and the majority of women with pregnancy or delivery complications have no risk factor in their medical or obstetric history. Therefore, all women should in principle have rapid access to life-saving emergency obstetric care. 4 WHO Essential Newborn Package.

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Comprised of a former British protectorate and an Italian colony, Somalia was created in 1960 when the two territories merged. Since then its development has been slow. After 1991 the country was plunged into lawlessness and warfare. Now considered a failed state, years of fighting between rival warlords and an inability to deal with famine and disease have led to the deaths of up to one million people. Somalia, comprising the three zones of North-West (NWZ = Somaliland), North East (NEZ = Puntland) and Central South Zone (CSZ), has an estimated population of 7.7 million people5, and an estimated 1.1 million Internally Displaced Persons (IDPs) (FSAU, 2008). Table 1.1 Population estimates for Somalia by zone (UNDP, 2006) Zone Males Females TOTAL NWZ 1.886.500 889.200 1.886.500 NEZ

455.400

433.800

889.200

CSZ

2.536.300

2.415.700

4.952.000

TOTAL 3.957.800 3.769.900 7.727.700

Overall, populations living in urban areas are estimated to comprise 35-40% of the population (ibid). The nomadic population comprises 10-20% of the population, depending on zone. The situation in Somalia has recently deteriorated to one of its worst levels in 17 years, particularly in the Central South zone. Currently 3.2 million people (43% of the population) are categorized as in crisis and in need of aid (ibid). 1.2.1

Current political context

Two administrations in the north, i.e. the North Western Zone of Somaliland and the North Eastern Zone of Puntland, have claimed regional jurisdiction and attempted to provide social services and maintain a level of law and order. Somaliland declared independence in 1991, and has until recently remained relatively stable and secure despite a lack of international recognition as a sovereign state. The relative security has attracted developmental activities and donor projects. Puntland declared itself an autonomous state in 1998, within the realms of the federal state of Somalia. Puntland and Somaliland have seen sporadic fighting over the disputed region of Sool and Sanaag. Deterioration in 5

81'3  6RPDOLD6HWWOHPHQW6XUYH\6HH-DUDEL%2³5HYLHZRIYDULRXVSRSXODWLRQHVWLPDWHG for Somaliland, Puntland and South-&HQWUDO6RPDOLD´  IRUDGHWDLOHGGLVFXVVLRQRQYDOLGLW\RI population estimates for Somalia.

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security over the last few years has hampered donor interest and investment in the zone, as has the emergence of piracy off the coast of Puntland. The zone has a majority of nomads among the population, as well as a large IDP population originating from the Central South Zone. Puntland is considered to have a high potential for eruption of conflict, also brought about by the recent increase in piracy along its coast. Few international NGOs work in RH in Puntland. With low or no capacity at governmental level, the Central South Zone has endured most of the fighting during the last few years and has contributed a high number of the IDPs and general population dependant on aid or diaspora remittances. This has left NGOs and UN bodies in charge of health coordination, and in some instances this has paradoxically eased implementation of work on the ground. NGOs are major actors in RH in the CSZ. The recent sharp deterioration in security has put a good number of planned interventions and projects on hold. The security events in Somaliland during October 2008 were followed by restricted access to this zone, which was previously considered a working base for all of Somalia. At the time of writing (February 2009), UN Security Phases IV and V were in place all over Somalia, with many expatriates relocated or evacuated. There is great uncertainty concerning the intermediate stability of Somalia, and especially the future humanitarian space. 1.2.2

RH health services and humanitarian assistance

(YHQEHIRUH%DUUH¶VIDOO, traditional areas of responsibility for the state - such as basic education and health systems - were poorly developed. Most health services were privatized and accessible to only a few, with a weak focus on public health. The level of government involvement and capacity in health is still weak, with some higher capacity in the northern zones. Present NGO programming on reproductive health tends to go beyond the Minimal Initial Service Package (comprehensive RH services for the first phase of an emergency or acute refugee situation) in some areas of care, but not in others. Due to the volatile situation few have moved on to comprehensive RH-frameworks developed and/or planned for post-conflict countries such as Afghanistan, Timor, the Congo, etc.

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1.3

Reproductive health in a Somali cultural context

A number of contributing factors influence reproductive health in Somalia (see Box 1.3). Box 1.3 Major socio-cultural factors influencing RH in Somalia Low levels of education and literacy High fertility and low demand/access to FP Gender status and the role of men Harmful traditional practices Poor health-seeking behaviour

1.3.1

Education, literacy and knowledge of RH issues

Knowledge of reproductive health rights and issues is very limited among Somali men and women, for many reasons. School enrolment remains low, with a gross enrolment in primary school of only 31%6. Overall female adult literacy rate is estimated to be 25% (45% in urban areas and 10% in rural areas), impeding their access to health information7. The majority of knowledge, attitudes and practices regarding RH issues are derived from traditional social networks, including traditional healers and sheiks (FSAU, 2007). 1.3.2

High fertility

A strong pro-natality culture where desired fertility is high, contributes to a considerable lifetime risk of obstetric death or disability for every woman. Children are highly valued, being seen as an asset to the lineage and an economic benefit. Birth spacing or limiting is a sensitive issue, often never discussed between husband and wife as children are considered as a gift from God. The teachings of the Koran are considered by many Somalis as being against the use of family planning methods. Many Islamic scholars have argued against this position, and the acceptance of FP is probably influenced more by current political and cultural (clan) streams than traditional religious taboo. There is a high level of misconceptions of modern family planning methods, such as it causing permanent infertility. 1.3.3

Gender status and the role of men

Due to the inferior status of women in Somali society, ZRPHQ¶V¶ health has traditionally received little in the way of attention or resources. Husbands and 6

UNDP 2006 Multiple Indicator Cluster Survey (MICS), UNICEF 2006. The MICS studies from 2000 and 2006 are the most recent countrywide multiple-cluster surveys from all Somalia containing estimates of reproductive health indicators 7

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brothers, but also a womaQ¶VRZQPRWKHURUPRWKHU-in-law, are powerful figures who make most household decisions such as when to seek health care, and from whom, when and where to seek help for complications during pregnancy or during delivery, and the use of family planning. Influence on important choices concerning RH matters is executed via financial control over family resources. Men have traditionally had this control, but with an increasing proportion of households becoming headed by females or with economically active females, especially in IDP communities, this pattern might be changing. 1.3.4

Harmful traditional practices

Widespread traditional practices such as almost universal (98%) female genital mutilation (FGM) among women, are still present all over Somalia. FGM types II and III are associated with negative obstetric outcomes both for the mother and the neonate (WHO, 2006a). Early adolescent marriage and pregnancy before the age of 18 are common, increasing obstetric risk. Particular practices and taboos are in place in pregnancy, during birth and lactation. Added to strong preferences for home births and seclusion after birth, this is contrary to the use of modern health services for reproductive health. 1.3.5

Health-seeking behaviour

Most health-seeking responses are based on traditional knowledge, beliefs and perceived causes of specific illnesses. Across all livelihood zones, the initial response to disease is prayer. After that, traditional home health practice will often be tried, after which a traditional healer might be called. If this is not successful, medicine can be bought from a pharmacy. The next step could be getting a sheik to offer prayer and lastly, the option of seeking care at a health facility is used (FSAU, 2007). Illnesses which are not well understood are believed to be caused by the evil eye. Health-seeking behaviour is thus characterized by low confidence in modern medicine, especially regarding the benefits of preventive modern medicine such as vaccination. Misconceptions such as harmful effects of child vaccination, TT-vaccination in pregnancy causing infertility etc, are prevalent. Men, as major decision-makers regarding RH-services, might resort to violence or punishment should a wife disobey them and seek certain RH services such as family planning. Use of and trust in health facilities for reproductive health services such as facility-based birth is low for many reasons, and is often considered a last resort. Somalis generally value curative services such as surgical and medical interventions, with a strong emphasis on drugs. Health services are commoditized, and the understanding of public health is also low among decision makers within government bodies. Some services, such as antenatal care, seem to be in some demand despite their preventive nature.

22

1.4

Reproductive health indicators for Somalia

Table 1.2

Reproductive health indicators for global monitoring89. Somalilnd

Puntland

Central South Zone

All Zones

Source

5.9

6.2

7.1

6.7 /6.2

4.6%

0.1%

0.3%

1%

MICS 2006/ WHO Statistical Information System (WHOSIS) 2008 MICS 2006

Unmet Need Birth spacing/child limiting

29%

19%

26%

26%

MICS 2006

Maternal Mortality Ratio (MMR) Annual No.

No zonal estimate

No zonal estimate

No zonal estimate

1044 1400

MICS 2006/ WHO, UNICEF,UNFPA,World Bank, 2007

32% (10.3%)

26% (5.8%)

24% (5.2%)

26 % (7.1%)

MICS 2006

17%

21%

30%

26%

MICS 2006

21%

8%

6%

9%

MICS 2006

21%

7%

6%

9%

Derived estimate/MICS 2006

1.1

0.5

1.3

0.8

UNICEF/UNFPA 2006 (NWZ/NEZ)

1.7

2.2

1.7

1.9

UNICEF/UNFPA 2006 (NWZ/NEZ)

0.4%

0.6%

No zonal estimate

0.5%

UNICEF/UNFPA 2006 (NWZ/NEZ)

21%

33%

No zonal estimate

20-33%

UNICEF/UNFPA 2006 (NWZ/NEZ)

No zonal estimate

No zonal estimate

No zonal estimate

81

6%

11%

21%

17%

Neonatal and Perinatal Mortality. Geneva, MPS/HQ, 2007 Derived from MICS 2006

94%

98%

99%

98%

MICS 2006

1.4%

1.0%

0.6%

0.9%

WHO 2004

Indicator Total fertility rate (TFR) Modern Contraceptive Prevalence Rate (CPR) women 15-49 y

of maternal deaths /100,000 live births

Antenatal Care Coverage % women at least once during pregnancy. (% with at least 4 visits)

Coverage of tetanus vaccination (TT 2+) Proportion of births in a health facility Percent of births attended by skilled health personnel according to WHO def.

Availability of BEMOC No. facilities /500,000 population

Availability of CEMOC No. facilities /500,000 population Caesarean section as proportion of all live births Case Fatality Rate (direct obstetric morbidity in EmOC-facility)

Perinatal Mortality Rate Low Birth Weight Prevalence* Reported Prevalence of Women with FGM HIV prevalence among pregnant women

8

Due to lack of systematic population registration as well as figures for births and deaths, estimates concerning mortality and coverage are uncertain. For this report, population figures to estimate coverage RIVHUYLFHVDQGFRQGLWLRQVDUHWDNHQIURP81'3¶V6RPDOLD6HWWOHPHQW6XUYey. 9 For complete definitions of indicators, see Annex A

23

Indicator

Knowledge of HIVrelated prevention practices (% aware that

Somalilnd

Puntland

Central South Zone

All Zones

Source

No zonal estimate

No zonal estimate

No zonal estimate

11% (women) 24% (men)

HIV KABP 2004

No zonal estimate

1.9%

No zonal estimate

1.1%

WHO Sero-surveillance survey 2004/2007

No zonal estimate

No zonal estimate

condom use prevents transmission)

Positive syphilis serology prevalence in pregnant women Reported incidence of urethritis** in men Prevalence of anaemia in pregnant women Percent of obstetric and gynaecological admissions owing to abortion Reported prevalence of women with FGM, any type * **

No zonal 4.4% estimate No data

HIV KABP 2004

No data

94%

98%

99%

98%

MICS 2006

Estimated value (see MICS, 2006) Discharge in the past six months

Despite difficulties obtaining reliable statistics for Somalia, there is no doubt that core health indicators reflect a poor situation. Concerning maternal mortality, the shown estimates of an MMR of 1,044-1,400/100,000 live births is one of the highest in the region, corresponding to a lifetime risk of one in every 10 women. The methodology used in the MICS 2006 was the sisterhood method, and the numbers thus reflects the situation prevailing 10 to 12 years before the survey (1994-96). The MICS 2000 concluded with a MMR of 1,600, but confidence intervals are wide. Reaching MDG 5 concerning maternal mortality will require achieving a MMR of below 400 by 2015. 1.4.1

Obstetric factors contributing to high MMR

The high MMR is to a large degree rooted in obstetric factors among Somali women such as: a) Low age at first birth b) High fertility c) Low skilled attendance at birth/few institutional deliveries d) Limited access to emergency obstetric care e) Suboptimal nutritional status f) High prevalence of FGM

24

a) Low age at first birth Perceived age at first sexual intercourse is 15 years in women, and age at first marriage for women is 17 years (UNICEF Somalia, 2004). Teenage pregnancies are not uncommon and carry an increased obstetric risk for both mother and baby. The age-specific fertility rate for the 15-19 years age group is 123/1,000 women10. Fertility peaks in the 25-29 years age group, with 306/1,000 women. The rural fertility rate for young women between 15 and 19 years is higher than the urban rate: 140 vs. 102 per 1,000 women. b) High number of pregnancies per woman The high fertility rate of 6.7, mirrored in the low rate of use of modern contraceptives, exposes a woman again and again to risk of dying or disability. Poor spacing exposes children to higher risks of dying. c) Low skilled attendance at birth Actual skilled attendance - defined as a skilled attendant at birth operating in an enabling environment - is low (discussed hereunder). d) Suboptimal health and nutritional status In childhood and during childbearing years, Somali girls and women are at risk of macro-and micronutrient deficiencies. Disease or malnutrition in childhood can cause stunting and skeletal deformities of the birth canal that can cause obstructed labour. Closely-spaced and many pregnancies deplete stores of iron, vitamin A and folate, and dietary intake is normally inadequate for replenishment. There is evidence of a practice of certain food reductions and food taboos, especially in the third trimester, as this is perceived to reduce the size of babies at birth (FSAU, 2007). Maternal malnutrition increases the risk of a low-weight baby, one of the main causes of neonatal deaths worldwide. In Somalia there are no nationwide data concerning the prevalence of anaemia in pregnancy or the percentage caused by iron deficiency. Large-scale prevalence studies on Vitamin A and iodine deficiencies and protein-energy malnutrition among pregnant and lactating women, are mostly missing. The incidence of pregnancy-associated malaria is currently unknown. UNICEF is planning and has started implementation of, a larger study addressing many of these knowledge gaps. e) High prevalence of FGM Ninety-eight percent of Somali women have undergone FGM (MICS, 2006). FGM types II and III, which account for 79% of all FGM in Somalia, is associated with increased obstetric complications for mother and baby. According to a WHO study WHO (2006a). of FGM in six countries11, women 10 11

MICS 2006 Burkina Faso, Ghana. Kenya, Sudan, Nigeria, Senegal.

25

with FGM are significantly more likely to have adverse obstetric outcomes than those without FGM, and risks are greater with more extensive FGM. The study documented increased risk of postpartum haemorrhage, need for Caesarean section, stillbirth or early neonatal death with FGM type II and III. Parity did not significantly affect these risks. Box 1.4 Types of FGM * Type I:

Excision of the prepuce, with or without excision of part or the entire clitoris.

Type II:

Excision of clitoris, with partial or total excision of the labia minora.

Type III:

Excision of part or all of the external genitalia and stitching/narrowing of the vaginal opening (infibulation).

Type IV:

Pricking, piercing or incising of the clitoris and/or labia. Stretching the clitoris and/or labia. Cauterization by burning of the clitoris and surrounding tissue. Scraping of tissue surrounding the vaginal orifice (anguriya cuts) or cutting of the vagina (gishiri cuts). Introduction of corrosive substances or herbs into the vagina to cause bleeding or for the purpose of tightening or narrowing it. Any other procedures that fall under the above definition.

*

UNFPA/The World Bank, 2005

In Somalia, re-suture after birth is reportedly not widely practiced, unlike in countries such as Sudan where it is almost universal Gordon et al, 2007). Survey data are presently not available. 1.4.2

Major causes of maternal death in Somalia

Worldwide, the main causes of maternal death and disability are complications arising intra-partum such as haemorrhage, eclampsia, sepsis and obstructed labour12. Unsafe abortion is the only major cause of death that does not occur in late pregnancy/ delivery/ postpartum.

12

In populations with high socioeconomic standards of living, with adequate nutrition and modern education and literacy that refuse modern obstetric care and modern family planning methods, the maternal mortality rate is much lower, usually around 100 /100,000 live births (King).

26

Figure 1.1 Percent distribution of maternal deaths in Africa, by cause, 19972002 (WHO, 2006b).

Most maternal deaths occur within 48 hours after delivery and the rapid development of certain conditions e.g. postpartum haemorrhage, explains why timely referral is so difficult to achieve (see Box 1.5) Box 1.5 It is estimated that, if untreated, death occurs on average within: 2 hours from postpartum haemorrhage (PPH) 12 hours from ante partum haemorrhage (APH) 2 days from obstructed labour 6 days from infection

There are no comprehensive data on causes of maternal deaths in Somalia, as only facility-based deaths are registered systematically, and there are no systematic verbal audits or autopsy done. The main causes of maternal deaths in Somalia are believed to be ante- and postpartum haemorrhage, obstructed labour, pregnancy-induced hypertensive disorders and puerperal sepsis. In an assessment of 384 hospital records from Northern Somalia in 2005, 48% of direct maternal deaths were due to obstructed labour (UNICEF/UNFPA, 2006).Other important contributors were retained placenta (31%) and eclampsia (10%). Cases of postpartum haemorrhage (PPH) are

27

unlikely to reach hospital level, and are thus under-registered. PPH is normally estimated to account for 25-30% of maternal deaths in low-income countries (WHO, 2006b). Causes of indirect maternal deaths in Somalia are pre-existing conditions such as malnutrition, malaria, anaemia (affecting around 20% of pregnant women) and hepatitis. Admission numbers from regional hospitals in the NWZ show intrauterine death and abortion as common pregnancy complications (Ministry of Health and Labour Somaliland). Pregnancy-associated malaria (PAM) is associated with placental infection, which can cause abortion, premature birth and low birth weight but which can also be lethal for the mother, especially for nulliparas who have not acquired immunity. Malaria is endemic in Somalia, but prevalent in the river areas of the south (Shabelle, Juba) as well as in the central areas of the country. Intermittent preventive treatment in pregnancy is the protocol in the CSZ, but due to low prevalence is not considered relevant for the two northern zones, according to WHO protocols, 2008. 1.4.3

Major causes of maternal morbidity after complicated deliveries

The most serious is obstetric fistula. Others are chronic infection, urinary disorders, chronic anaemia, secondary infertility and post-traumatic psychiatric disorders. 1.4.4

Peri- and neonatal mortality

Neonatal mortality is estimated at 41-49/1,000 live births in Somalia. Most early neonatal mortality13 is linked to conditions of pregnancy and birth, as well as congenital malformations. Causes of newborn deaths linked to conditions of care in Somalia are low birth weight and prematurity, birth asphyxia, birth injuries, septicaemia and neonatal tetanus, but exact prevalence figures do not exist. Intrauterine death or stillbirth is a common complication of pregnancy14. There are no reliable registration of perinatal deaths, as reporting of stillbirths and preterm births outside of facilities does not take place. However, WHO estimates that perinatal mortality rate in Somalia was 81 per 1,000 total births in 2006 (WHO, 2007).

1.5

Methodology

The methodology used for this report was a combination of literature search, semi-structured interviews with focal points and key informants within UN bodies, NGOs and other actors active in the field of RH based in Nairobi and 13

Death during the first week after birth. IUFD, stillbirths and early neonatal deaths must be seen as a continuum; with better pregnancy and delivery care, more conditions will be diagnosed intrauterine leading to interruption of pregnancy by induction of labor or CS, but with a certain risk of postnatal death. An intrapartum birth asphyxia leading to fresh stillbirth in a setting with poor obstetric care might in another setting lead to emergency CS and thus a risk of neonatal death instead. The perinatal death rate is a common expression of this. 14

28

Hargeisa. During the time of the consultancy, access to the CSZ and NEZ was restricted. Many field staff from these zones were relocated, and thus became accessible for interviews in Nairobi. 1.5.1

Literature search Locally available information

The needs assessment was performed using a broad literature search. Most of the literature was gathered by contacting implementing NGOs and the main UN agencies (UNFPA, UNICEF, WHO) to get reports, assessments and evaluations. Websites of these agencies were assessed for relevant information. Comparable reference literature from other settings Internet searches were made to access reference literature and evidence-based interventions in the field through use of Pub Med and other search engines. Due to the scarcity of literature and research from Somalia, an effort was made to find evidence-based interventions, best practices and experiences from comparable settings in other countries. 1.5.2

Semi-structured interviews with key informants on RH

Major partners implementing core reproductive health activities in the three zones were contacted in Nairobi, and their recent and ongoing primary activities in the field of RH were mapped. Semi-structured interviews with focal points for RH from relevant NGOs, UN agencies, consultants and resource persons were also conducted. Key actors in Hargeisa were interviewed within the public and private sector, including professional associations. 1.5.3

Visits to health facilities and key actors in Hargeisa town, Somaliland

Visits were made to the Ministry of Health and Labout (MoHL), and to public and private health facilities within Hargeisa town. Key actors and individuals representing the medical community, facilities and organizations within reproductive health were interviewed. A list of institutions and persons visited and interviewed is included in Annex B. During the interviews, ongoing interventions were discussed against known efficient evidence-based practices, where these exist and where relevant in a Somali context. 1.5.4

Needs assessment

Needs assessment and gap analyses were conducted both by RH topic and by zone, using available monitoring and evaluation tools. For the definition of signal functions of emergency obstetric care; Basic Emergency Obstetric Care (BEmOC) and Comprehensive Emergency Obstetric Care (CEmOC), the UN process indicators were used (see Annexes C and D).

29

1.5.5

Period of data collection

Data collection was done during the period November 2008 ± February 2009, in both Nairobi and Hargeisa (four days). 1.5.6

Zonal differences in available information

For the North Western (Somaliland) and the North Eastern (Puntland) Zones, data from several assessments of emergency obstetric care were available, the most comprehensive and recent of which was conducted in 2006 by UNICEF/UNFPA15. For Central South Zone, no similar comprehensive assessment has been made and data have been mostly collected from reports, assessments, facility statistics and interviews with persons responsible for RH with major NGOs operating in the zone. Due to differences in reported indicators and statistics, numbers were not always comparable. Information on RH services offered by private health systems, such as private clinics or pharmacies, was extracted from secondary sources. For other areas of RH, written assessments of needs are patchy and do not follow the same methodology nor cover all zones, but give a qualitative indication of the status of RH needs. The private sector is underrepresented in assessments and reports, and information was difficult to obtain given the restricted access. 1.5.7

Limitations of the study

There is a general paucity of impartial information regarding health status and indicators in Somalia. As a mainly literature study, information for this report had to rely on secondary information from several often contradictory sources. No central library in the field of reproductive health in Somalia has been set up. Gathering of core documents, assessments, reports and/or evaluations from different actors had to be collected from original or secondary sources. As such, a lot is left to be desired when it comes to sharing of information. Institutional memory tends to be short and staff turnover in NGOs and UN bodies high, and several fairly recent reports referred to in the literature could not be located. As a primarily desk assignment to obtain data and information from the field it was necessary to rely on many different sources of data that sometimes did not agree. Most have been included so as to try and present as complete a picture as possible. Lack of access due to the security situation in the NEZ and CSZ made field visits to these zones difficult. There is disagreement regarding estimated population numbers for Somalia (UNDP, polio numbers, MoHL). Catchment populations of facilities are therefore not defined, and estimates of coverage of services are surrounded by a great deal of uncertainty. 15

UNICEF/UNFPA (2006). Needs Assessment of Emergency Obstetric Care in Somaliland and Puntland.

30

The situation in Somalia changes rapidly, and there is always a risk that information is out of date. This will nevertheless not have a dramatic impact on the central recommendations of this report. 1.5.8 Disclaimer This report reflects the views and opinions of the author only, and does not represent the views or positions of any public or private agency.

31

2

Service delivery

2.1

Health systems, infrastructure and service delivery

Figure 2.1 Health systems in Somalia

Ministry of Health

PUBLIC Public hospitals Health centers/MCH Health posts

PRIVATE Private hospitals Pharmacies Private clinics

INFORMAL Traditional healers Sheiks Community volunteers

Health systems do exist in Somalia, but in most parts of the country these are characterized by a general disintegration due to lack of a functioning central political authority and/or adequate public finances. The health system consists of a number of non-standardized facilities offering different levels of care, both private and public, with little formal organization. Furthermore there are no clear links between facilities at different levels and thus no systematic referral system. Some facilities are supported by NGOs or UN bodies, and some are not. Support takes place in varying degrees regarding rehabilitation of infrastructure, supply of medical drugs or equipment, incentives to staff, supervision and training. Community support is estimated to be considerable, but is disorganized and unpredictable. Community funds are from out-ofpocket expenditure, community pooled funds, business contributions, charitable/religious donations and diaspora remittances, and are often managed by community health committees. Staffing patterns and payments at different levels are highly variable. Rural facilities are commonly understaffed, particularly with respect to professional health staff. MoHL salaries are too low to support livelihoods and are often interrupted, accounting for poor staff motivation and engagement in dual work places. With regard to availability of services, there is generally better access to a broader range of higher quality services in urban than in rural areas. Special facilities have in some cases been set up to cater for needs of IDP-

32

populations, but mostly in the urban areas. Few services are specifically targeting nomadic or rural-nomadic populations. Health facility management systems are either non-existent, or rarely applied. NGO-supported facilities might have accountability systems in place, but are compromised by their reduced presence due to insecurity on the ground. Table 2.1

Health facilities for reproductive health in the three zones

Source: UNICEF Somalia, 2008

Somaliland Puntland CSZ Totals 2.1.1

Health Posts

MCHs

District Hospital

Referral Hospital

160 120 264 544

70 44 134 248

8 4 15 27

1 1 5 7

Referral/hospital level

Most hospitals were built 40-50 years ago, with outdated architectural designs and size, and are located in urban areas. Most are underutilized due to inadequate running of services and lack of qualified staff. Bed occupancy tends to be low. Some are private and some public, but with little distinction to the consumer in terms of user fees or the services provided. 2.1.2

Health Centres (HC = Maternal Child Centres (MCH))

A prototype HC or MCH has been defined according to the Essential Package of Health Services16, but has not yet been rolled out. Core activities of a HC are preventive and curative services such as ANC and OPD functions. The majority of services provided are curative, and volume-wise RH services constitute a minor activity. A minority of health centres function as normal delivery points. Regarding staff for RH, some are staffed by at least one qualified midwife but many are not. Most have several auxiliary midwives with varying qualifications and experience, any of whom might actually turn out to be a trained TBA. Concerning infrastructure, many operate without running water or electricity, but most have a cold-chain. There are usually no in-patient facilities or, if present, are not utilised. 2.1.3

Health posts

There are over 600 health posts, of which a few are supported by NGOs with very varying levels of functioning and staffing. Staff are unpaid, mostly untrained, unsupervised, and no health information is collected. Currently, regarding reproductive health, some health posts offer assistance to pregnant women such as giving out preventive drugs, but this is not a comprehensive ANC package. Very few serve as a delivery point. They are normally staffed by community health workers (CHW) or a TBA. Outreach

16

UNICEF Somalia (2008).The Essential Package of Health Services (EPHS). Final Draft.

33

activities are not standardized and most surveys demonstrate poor coverage of nomadic and rural populations. 2.1.4

Pharmacies, private clinics & laboratories

There are a number of for-profit private medical clinics, some of which are attached to pharmacies and laboratories, which offer curative services. There are estimated to be more private facilities than public ones offering services ranging from consultation, lab, clinical exam and/or sale of drugs, to higher level interventions such as surgery. The quality of services has not been assessed in recent years, and are likely to vary greatly due to diverse staff qualifications. ANC and postnatal care are offered, and some private clinics run by midwives also offer delivery services. For major surgery such as a CS, the patient will in most cases be taken to either a private or public hospital. 2.1.5

Maternity waiting shelters

Developed as an alternative to decentralization of EmOC services, maternity waiting homes are residential facilities located near an established referral PHGLFDOIDFLOLW\ZKHUHZRPHQGHILQHGDV³KLJKULVN´FDQDZDLWWKHLUGHOLYHU\ or be transferred to shortly before delivery or earlier, should complications arise. Many consider maternity waiting homes to be a key element of a strategy to bridge the geographical gap in obstetric care between rural areas with poor access to equipped facilities, and urban areas where services are available. In Somalia, maternity waiting shelters exist in conjunction with a handful of referral facilities, but all are ad hoc in nature. Currently there is no existing national programme of maternity waiting shelters in Somalia.

2.2

Proposed framework for delivery of health services

The Essential Package of Health Services (EPHS) developed by UNICEF in 2008 is a comprehensive plan for the remodelling and creation of a future Somalia health system. It has been endorsed by the MoHL Somaliland and de facto by the MoH of the Transitional Federal Government in the CSZ. The EPHS has a strong focus on MCH. 2.2.1

Reproductive health components of the Essential Package of Health Services

The EPHS has established which levels of the health system will deal with maternal, reproductive and neonatal health (Table 3.9). For details, see Annex E. In this model, the first comprehensive contact point for all maternal and neonatal health services will be at health centre level (Level II). At this level basic services such as antenatal care, delivery care, BEmOC, postnatal care, FP and STI treatment will be offered. At a lower level (Level 1 ± Primary Health Unit) some elements of reproductive health will be included, such as aspects of family planning and promotion as well as prevention of STI and promotion of care seeking behaviour. The referral health centre (Level III)

34

will in addition offer CEmOC. Referral hospitals (Level IV) will offer the full range of reproductive health services, including gynaecological and fistula surgery. Figure 2.2

Table 2.1

Proposed reproductive health services and staff at different levels

Level Phase Services

Cadres

Primary health unit I II Maternal, reproductive & newborn health HIV,STI & TB

Community midwife Nursemidwife Doctor Prof. qual. for CS

FP & promotion Prevention & promote care seeking behaviour -

Health centre I II

Referral health centre I II CEmOC

BEmOC

Hospital I

II

CEmOC gynaecological & fistula surgery

HIV test

Increase VCT

VCT + PMTCT

Increase ARV

ART + PMTCT All regions

1-2

1

2

-

-

-

12 1

2

2

3

3

4

-

-

-

0 1

1 1

2 2

4 3

(For definition of health staff, health management structures, see Annex E).

The EPHS includes detailed plans for linkages between the different components of the health system and referrals between levels. It also describes health system support components such as drug supply, transportation, communication and physical maintenance and repair. Regional supervision and management structures have been developed (Annex E).

35

The emphasis of the EPHS is to improve the quality of service provision and not, in the first phase, the quantity of health facilities created. Once quality can be assured and further financing secured, services can be expanded.

2.3

General barriers to access

Barriers to accessing reproductive health services are many. There are demand-side barriers such as delay17 at household level due to poor understanding of reproductive health risks, and often justified low confidence in what health facilities can provide. There is a strong perceived association between hospitals and bad outcomes for the mother. Hospitals are viewed as a last resort, as costs and logistics concerning care and transport are forbidding. In addition, hospitals are frequently considered inappropriate for delivery care due to e.g. violation of privacy connected to vaginal exams and undesirability of Caesarean section. High transport and services costs, long distances and difficulties in finding transport and high out-of-pocket expenditures are among logistic and financial barriers that are met, even when the primary delay is overcome. There are supply-side barriers such as delays at facility-level in obtaining timely medical care, due to poorly functioning referral centres. Specific barriers will be discussed under each service delivery section.

2.4

Quality of services

In general, the quality of reproductive health services outside of a few (private) facilities is compromised by a lack of quality staff and human resource management, lack of equipment and/or training to use existing equipment, or inadequate, inefficient management and supervision mechanisms. There are no quality control mechanisms of services in place, neither in the private nor the public sector.

2.5

Safety

Regarding safety of services, there are no legal certification bodies for health staff cadres, and health staff continue to operate in the public and private sectors in areas outside their formal training and competencies. There is no existing ethical code of conduct for health personnel, and the private sector is completely unregulated. There are no protection mechanisms for patients FRQFHUQLQJWKHKHDOWKSURYLGHU¶VGHVLUHIRUSURILW,QERWKWKHSXEOLFDQG private systems there are high levels of case fatality rates in maternity wards, pointing to poor quality services (UNICEF/UNFPA, 2006). Access to safe blood services is poor outside the major urban areas. Blood transfusions often rely on the less safe option of immediate blood products of 17

The three delays were formulated by Thaddeus and Maine in 1991. Delay in seeking care is presented in three ways. The first is in the decision to seek care, the second is in reaching a facility after the decision is made and the third is in receiving needed care when at facility-level.

36

a relative, rather than a facility blood bank. In CEmOC centres in the NWZ, 55% of transfusions were from a relative/neighbour and in the NEZ 36% were from a relative/neighbour (ibid). Box 2.1Main reproductive health services 2.1 Essential delivery care 2.2 Emergency Obstetric Care 2.3. Newborn Care 2.4 Antenatal Care and Postpartum Care 2.6 Family planning/Birth spacing 2.7 Obstetric Fistula 2.8 Post-abortion Care 2.9 Prevention and treatment of STI/HIV-AIDS 2.10 Medical Response to victims of Sexual- and Gender-Based Violence 2.11 Adolescent and Youth Reproductive Health Programs 2.12 Infertility and cancer of the Reproductive Tract Organs

2.6

Essential delivery care

Table 2.3 Indicators Delivery in health facility

9.4 %

MICS 2006

Percent of Births Attended by Skilled Health Personnel*

33 %

MICS 2006

50.9 %

MICS 2006

TBA assisting at birth

*includes auxiliaries, nurses/midwives, doctors

2.6.1

Where do women give birth?

Over 90% of deliveries take place at home in Somalia. The MICS 2006 study showed that countrywide, 9.4% of births occur at health facilities. Around 25-50% of MCHs conduct normal deliveries within the facilities, but more commonly ELUWKVDUHDVVLVWHGLQWKHZRPDQ¶Vhome. The data below show registered numbers of deliveries by MCH staff or associated staff (TBAs)

37

Table 2.4 Number of deliveries reported by MCHs supported by UNICEF, by zone Source: UNICEF, 2008

Zone NWZ NEZ CSZ TOTAL

Attended* deliveries in facility

Attended* deliveries out of facility

Total deliveries attended*

% of expected deliveries attended

2200 1500 6000 9700

9800 2200 16400 28400

12000 3700 22400 38100

13 <10 <10

* µ$ttended¶ does not imply skilled attendance.

Concerning hospital deliveries, most facilities have a fairly low number of yearly births. District hospitals typically have 100-500 births/year, whereas regional hospitals range from 2,000-3,500 in the most productive hospitals (HGH, SOS Kinderdorf), to 300- 400/year in the least productive (Erigavo Regional H, Burao Regional Hospital). This translates to a range of 5-10 deliveries to one delivery per day, respectively. Somaliland A KAP baseline survey conducted among urban IDPs in Somaliland in 2008, showed that 75% of births occurred at home and 23% at a health facility. Sixty-six percent of respondents were assisted by a TBA (Health Unlimited Somalia, 2008). MoHL 2006 data from three regional (HGH, Burao H and Boroma H), one private (Edna Adan Hospital) and one district hospital (Gabiley H) showed between 87-95% normal deliveries of women admitted (Ministry of Health and Labour Somaliland, 2006).

2.6.2

Who attends at birth?

Table 2.5 Attendance during delivery Percent distribution of women aged 15-49 with a birth in two years preceding the survey (Source: MICS, 2006) Person attending delivery (%)

Zone NWZ NEZ CSZ

Medical doctor

Nurse/ Mdwfe

Auxiliary midwife

Traditional birth attendant

Relative/ friend

No attend.

Delvrd in health facility

19.5 5.3 3.4

1.5 1.6 2.7

20.4 29.9 23.7

37.0 47.1 55.9

18.5 13.1 9.4

1.2 2.0 3.2

21.4 7.9 5.8

15.3 2.3

5.4 0.5

44.3 11.8

29.5 63.3

3.8 16.4

3.8

3.0

Residence

Urban Rural

The MICS 2006 indicated that 33% of births are attended by skilled personnel (defined in the study as either medical doctor, nurse/midwife or auxiliary midwife). In Somalia, many women occupying positions as auxiliary midwives are actually trained TBAs. Other surveys, e.g. one from the rural

38

area of Togdheer region, Somaliland, found 18% skilled attendance (excluding auxiliary midwives), mainly nurse/midwives (16.5%) and a small proportion of doctors (1.6%). The majority (45%) were delivered by a TBA. 2.6.3

Skilled attendance

Skilled attendance is by international consensus, GHILQHGDV³DWWHQGDQFHDW birth by skilled personnel in an enabling HQYLURQPHQW´ (WHO/ICM/FIGO, 2004). Skilled personnel are defLQHGDV³DQDFFUHGLWHGKHDOWKSURIHVVLRQDO± such as a midwife, doctor or nurse ± who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and QHZERUQV´ LELG , 2004 ³Skilled personnel´ implies being trained in conducting normal deliveries, first line treatment of obstetric complications and an ability to timeously diagnose complications for referral. This normally includes doctors, midwives and nurses with some training in midwifery skills. Given the difficulties of assessing staff competence and qualifications in Somalia, estimates of numbers of skilled attendants will at best be crude. An enabling environment is meant to describe a health system that has the ability to support the health worker in performing her/his tasks. For delivery care, this will include available support staff that can assist the trained staff, equipment and drugs (such as urine catheter, essential obstetric drugs such as oxytocine, clean infusion sets or IV needles), adequate physical premises (lights and clean water). Few deliveries outside of a few hospitals in Somalia presently comply with this point18. According to the prevailing definition, the actual coverage of skilled attendance is likely to be extremely low in Somalia. 2.6.4

Traditional birth attendants

Traditional birth attendants usually play a role in pregnancy care only during labour and delivery. They are normally illiterate, FRPHIURPWKHZRPDQ¶VRZQ community and clan, and only operate within a limited geographical area. They are occasionally contacted if a problem arises during pregnancy, but traditionally their role during the antenatal and postpartum period has been very limited or non-existent19. 18 Ecologic studies have shown that skilled attendance at delivery is not associated with a reduction in stillbirths and maternal deaths until reaching skilled coverage of around 40% (McClure et al. 2007). The assumption is that skilled attendance at those levels is associated with highly developed health systems as an enabling environment, not necessarily reflecting the actions of skilled attendants per se. 19 A TBA will in some cases be the same person who circumcised the woman many years back, and ideally the same TBA should be there during delivery to open her. The trade will often be inherited by a daughter or niece, who learns the trade when the aging TBA is too old or incapacitated. It is a limited incomegenerating activity and most TBAs will be reimbursed or given gifts (food, household items) for their assistance. There are vast differences in how active TBAs are; some will only conduct a few deliveries a year, while some will assist weekly, depending on the size of her catchment area. Even an experienced TBA might only encounter a particular delivery complication a few times during her active career and will thus not have empirical knowledge of what works in a given situation. Concerning referral, the advice of the TBA is only one among many when it comes to the decision of whether to refer a woman. Other family members, sheiks and traditional healers will often be contacted for their opinion.

39

Many efforts have been made to improve services for women at community level by targeting the TBAs. Training and support with materials and supplies have been made available to TBAs by the previous governments of Somalia, and by NGOs that have been supporting health programs since the ¶s. The number of TBAs that are trained in Somalia is unknown, as are any standardization of type, length and frequency of training. Their age profile or background characteristics have not been assessed. 2.6.5

Effect of TBA training programs on maternal and neonatal survival in Somalia

A Cochrane review from 2007 concluded that there is limited evidence that trained TBAs, as part of concerted health system strengthening effort, can have a positive impact on newborn survival (Sibley et al, 2007). Impact on maternal mortality could not be established. Concerning morbidity, studies have shown that training TBAs in clean delivery does not prevent postpartum infection in the mother (Goodburn, 2000). In the WHO 2004 definition of skilled birth attendant, the TBA was left out, trained or not trained. An evaluation undertaken by UNICEF concluded that TBA support programs existing as isolated activities are unlikely to have any effect on maternal mortality (UNICEF Somalia, 1998). New perspectives on the role of TBAs have been to continue to include them in the health system, but rather for recognition of complications and early referral as well as improving neonatal practices. Many agencies in Somalia are still conducting TBA training but the emphasis has shifted to early referral and neonatal care, rather than delivery care. Trained or untrained TBAs are still major actors in delivery care. 2.6.6

Quality of birth care

With regard to women delivering with skilled personnel in a facility, the actual quality of care is questionable. Presently almost no MCHs offer the complete range of BEmOC. Oxytocine and misoprostol for active management of labour, induction of labour and primary prevention of PPH are often not available. Oxytocine is not part of the current standard health centre kit supplied by UNICEF, but is supplied in kit-form by UNFPA. Only 24% of health centres in the NWZ and 37% of health centres in NEZ perform active management of third stage labour, including the use of oxytocin. Ergometrine is the preferred oxytocics as it does not need a cold-chain, although EPI is normally part of the standard MCH services. Only 10% of all surveyed health facilities had ever used Misoprostol for managing PPH (UNICEF/UNFPA, 2006). Not unexpectedly, a higher proportion of hospitals perform active management of third stage. Of all facilities practising active management only 17% gave oxytocine within one minute of the delivery of the baby, and 63% gave it after the placenta was delivered. Twenty seven percent of hospitals in the NEZ reported often being out of stock of oxytocine, whilst 20% were often out of stock of Misoprostol (ibid).

40

A number of harmful practices that are considered obsolete in obstetrics, continue to be practiced. These are routine measures such as giving the birth woman an enema to speed up labour, shaving the genital area before birth, and performing routine episiotomy and amniotomy. The table below shows the percentage of EmOC facilities in the NWZ and NEZ that performed the following procedures as a routine. Table 2.6 Routine performance of potential harmful practices20 Enema

57% (NWZ+NEZ)

UNICEF/UNFPA 2006

Shaving

65% (NWZ+NEZ)

UNICEF/UNFPA 2006

Episiotomy

62% (NWZ+NEZ)

UNICEF/UNFPA 2006

Most qualified obstetricians and midwives in Somalia graduated before 1991 and with the lack of any continuing medical education, obstetric knowledge and practices deviate somewhat from present evidence-based practices. This illustrates the isolation of the Somali medical system. Somaliland The reporting of deliveries by trained TBAs is low, either reflecting poor reporting or a low percentage of training among TBAs. In Hargeisa region, 13% of deliveries are assisted by a trained TBA, whilst all other regions have lower numbers, the lowest in Sanag (2%)21.

2.6.7

From TBAs to skilled attendance

There is still debate concerning whether facility-based deliveries per se offer an additional benefit over home deliveries22, even though international opinion leans strongly towards institutional births for all, as skilled attendance can really only be achieved in a facility environment with

assisting staff, equipment, realistic and timely early referral possibilities. Excluding the TBAs fully from conducting delivery care leaves a huge gap, considering that there is a great shortage of trained health personnel and that 50% of all births continue to be assisted by TBAs. Presently there are no 20

These are procedures routinely practiced in the past which have been shown to be of no benefit or to be potentially harmful. 21 Ministry of Health and Labour Somaliland (2006). Annual Health Report 2006. 22 Within modern western health systems the transition from home to institutional deliveries for almost all women has played a limited role in the historical achievement of substantially lowering maternal mortality in many European countries during the 19th and 20th centuries to the current very low levels. The emergence of improved nutrition and hygiene, access to antibiotic treatment, blood transfusion and home midwifery services have instead been identified as the main reasons behind the dramatic lowering of obstetric death and disability (Tew, 1998).

41

community midwives operational in Somalia, but the first 20 community midwifes from Somaliland will graduate in 2009. The idea behind this cadre is to improve skilled attendance at home births and to cater to the needs of the rural population. The community midwife will naturally take over home births, which will continue to take place. She is more likely to remain in the rural area she is recruited from. TBAs can be recruited into the cadre if they meet the criteria, but TBAs might more naturally be eligible for retraining as female community health workers. 2.6.8

Conclusions

Normal delivery care in Somalia is characterized by a vast majority of home births conducted by unskilled staff, with significant urban-rural and socioeconomic differences in access to safe delivery. Skilled attendance, according to the definition of 2004, is seldom achieved outside of a few specific hospitals. In general, for facility-based deliveries in HC and hospitals, care quality is low, either lacking or with outdated protocols for standard interventions during normal childbirth, such as the use of oxytocics. A policy shift towards skilled attendance at births for all, will mean stopping support to TBAs conducting deliveries. To be able to offer better care in rather than out of facilities, comprehensive rehabilitation of existing facilities to create affordable quality BEmOC centres must take place. Measures to improve access to safe delivery for rural and nomadic populations, such as up scaling community midwifery and assuring maternity waiting shelters, will be essential. A role for TBAs in referral of deliveries as well as newborn care, might be necessary for rural and difficult-to-reach areas for the intermediate future.

42

2.7

Emergency Obstetric Care (EmOC)

Table 2.7Status of EmOC Value

Minimum recommended level

Source

Availability of Basic Essential Obstetric Care

0.8/ 500 000 population

4 / 500 000 population

UNICEF/UNFPA 2006 (NWZ+NEZ)

Availability of Comprehensive Essential Obstetric Care

1.9/ 500 000 population

1/ 500 000 population

UNICEF/UNFPA 2006 (NWZ+NEZ)

Case fatality rate (direct obst.compl)

21-33%

< 1%

UNICEF/UNFPA 2006 (NWZ/NEZ)

Caesareans % of all deliveries

0.5%

5-15%

UNICEF/ UNFPA 2006 (NWZ/NEZ)

Indicator

Somaliland Somaliland has the more-developed EmOC services as well as the most resources within the MoHL, of the three zones. Most of the population is concentrated in the western areas, with huge areas in the east where there are very few functioning facilities. For a comprehensive list of facilities providing obstetric care in Somaliland, see Annex F. A facility-based assessment of EmOC by UNICEF/UNFPA in 2006 in the NorthWest Zone (NWZ) covered a total of 85 health facilities (18 hospitals, 54 HC and 13 health posts), both public and private. Three main problems were identified with regard to EmOC-services: Many facilities without EmOC capacity Low level of utilization of EmOC in most regions Access to CEmOC hampered by long distances and rural population The major findings are referred in the table below.

43

Table 2.8 Summary of EmOC process indicators in NWZ Source: UNICEF/UNFPA 2006

Zone

NWZ

Population* Coverage of BEmOC facilities per 500,000 pop Coverage of CEmOC facilities pr. 5,000,000 pop % all births in EmOC facilities % of expected direct obstetric complications treated % of all births by CS CFR of direct obstetric complications

1.805.381 1.1 1.7 9.5 11.4 0.4 21.3

Min.level** 4 1 15 100 5-15 <1

*UNDP 2002 ** Minimum recommended level according to UN process indicators

The coverage of CEmOC facilities was higher than the minimum standard, but only 1.7 BEmOC facilities per 500,000 population, compared to four by UN standards, shows a major gap. The met need of emergency obstetric care was less than 12% (percentage treated of expected obstetric complications seen) as compared to the standard of 100%, showing the dramatic underutilization and low activity at EmOC facility level. A population CS rate of 0.4% is well below the recommended minimum level of 5%, showing that the CEmOC centres have far too low levels of activity. Normal deliveries take up quite a lot of resources at referral level, comprising between 87-95% of all live births in five major Somaliland hospitals in 2006 (Edna Adan Hospital, HGH, Burao, Boroma, Gabiley). 2.7.1

Underutilization of referral facilities

CEmOC facilities on average conduct a relatively small number of deliveries per year. According to the Somaliland MoHL report of 2006, 319 women were admitted to the maternity ward of Burao Regional Hospital during the entire year, and a joint assessment by UNFPA/UNAIDS/MoHL in the same hospital in 2008, concluded with on average two deliveries per day. The busiest hospitals have admission numbers of 2,000-3,000 /year, which translate to five to eight admissions/day (Hargeisa Group Hospital). To run a CEmOC facility efficiently and sustain professional staff, including 24/7 CS and anaesthesia capacity at a CEmOC centre, the number of admissions needs to be in the upper range. This is also true in keeping up professional skills of staff, as otherwise the necessary volume of obstetric complications will be too low. 2.7.2

Quality of care

The case fatality rate of 21% found by the assessment in 2006 is well beyond the recommended level of <1%. Late referral and suboptimal quality of care at referral point are among the reasons given. Concerning crucial signal

44

functions23 and routine procedures these were assessed by the percentage of facilities in NWZ that perform the below functions: Active management of third stage24: Hospitals: 53% HC: 24% Oxytocic used: Three percent of EmOC facilities used oxytocine as a first line parenteral drug for primary or secondary prevention of PPH. Thirty-six percent used ergometrine as first line. Management of eclampsia: Fifteen percent used MgSO4 as first line drug, and 46% used diazepam only. Thirty-three percent used a combination of the two. Assisted vaginal delivery: Twelve percent of facilities used only vacuum delivery, 29% only forceps and 59% offered both. 2.7.3

User fees

A normal hospital delivery can cost US$ 10-15 in Somaliland. An emergency CS in public or private hospitals can cost around UDS 160- 450 depending on the facility, with great variations. 2.7.4

Referral mechanisms

There is no appropriate referral system in place between facilities. Many HCs work without a realistic referral (>3-4 h) to a EmOC centre. In most cases, BEmOC centres are not located close enough to CEmOC centres for referral to be a reality. Existing communication and transport regarding referral between facilities were unsystematic and ad hoc, especially between HC and referral level. Ambulances were found at three hospitals, but the function was not assessed. Ambulance services as assessed in 2006 were not available on a 24-hour basis at any health centre. 2.7.5

Vouchers

Most NGOs did not have experience with prepaid voucher schemes for women referred during delivery for CS. It seems that some hospitals accept to waive HIV+ women who come for delivery (HGH), but the volume is very small.

23

Signal functions are used to evaluate the level of functionality of a medical facility to allow classification. Active management of the three stages of labour is a set of procedures recommended for the prevention and early treatment of postpartum haemorrhage (PPH). 24

45

2.7.6

Maternity waiting shelters

In NWZ six facilities (four hospitals and two MCH) had ad hoc waiting shelters on private initiative (UNICEF/UNFPA Somalia). The number of women using the facilities per month ranged from two to 75 (mean = 18). No evaluation has been conducted. Puntland For a comprehensive list of facilities providing obstetric care in Puntland, see Annex G. The facility-based assessment of EmOC by UNICEF/UNFPA in 2006 covered a total of 64 health facilities in Puntland (15 hospitals, 38 HC and 11 health posts, both public and private). The major findings are given in the table below. Table 2.9 Summary of EmOC process indicators in the NEZ Source: UNICEF/UNFPA 2006

Zone Population* Coverage of BEmOC facilities per 500,000 pop

Coverage of CEmOC facilities pr. 5,000,000 pop % all births in EmOC facilities % of expected direct obstetric complications treated % of all births by CS CFR of direct obstetric complications

NEZ

Min.level**

912.696 0.5

4

2.2 0.7 1.5 0.6 33.1

1 15 100 5-15 <1

*UNDP 2002 ** recommended according to UN process indicators

Three main problems were identified with regard to EmOC-services: Low level of utilization of EmOC in most regions Many facilities without EmOC capacity Access to CEmOC hampered by long distances and unfavourable disparity among rural populations The coverage of CEmOC facilities was higher than the minimum standard, but only 0.5 BEmOC facilities per 500,000 population as compared to four by UN standards, shows a major gap. The percentage of births in an EmOC facility was less than the recommended minimum of 15%. The met need of emergency obstetric care was less than 1.5% (as compared to the minimum standard of 100% treated of expected obstetric complications seen), pointing to dramatic underutilization and general low activity at EmOC level. CS rate was 0.6%, i.e. below the recommended minimum level of 5%, pointing to gross underutilization of CEmOC facilities.

46

2.7.7

Quality of care

The case fatality rate of 33% is well beyond the recommended level of <1%. Late referral as well as delay and poor quality of services at referral facility are among reasons stated. Main signal functions and routine treatments assessed as to percentage of EOC facilities that performed the below procedures: Active management of third stage: Hospitals: 60% HC: 37% Oxytocic used: Twenty percent of EmOC facilities used oxytocine as first line drug for primary or secondary prevention of PPH. Seventy-two percent used ergometrine as first line. Management of eclampsia: Fifteen percent used MgSO4 as first line drug, 79% used diazepam only. Zero percent used a combination of the two. Assisted vaginal delivery: Five percent of facilities used only vacuum delivery, 95% only forceps and 0% offered both. 2.7.8

User fees

There are wide variations in user fees, ranging from free to several hundred US$. A normal delivery in a Bossaso regional hospital costs 0.5 million Somali Shillings (US$ 16), whereas an emergency CS costs 3.0 mill SS (US$ 94)25. Cost-sharing is in place in most hospitals, even NGO-supported facilities. 2.7.9

Referral mechanisms

There are no appropriate referral system in place between facilities in NEZ. Many HCs work without a realistic referral (>3-4 h) to a CEmOC centre, or even BEmOC centres. 2.7.10

Communication and transportation

Both were found to be of suboptimal function between facilities, especially at HC level. Ambulances were found at two hospitals in the NEZ, but the function was not assessed. 2.7.11

Use of vouchers

Most NGOs did not have experience with prepaid voucher schemes for women referred to facilities for delivery or other obstetric interventions.

25

AAH, personal communication 05.02.09

47

2.7.12

Maternity waiting shelters

In the NEZ zone, two facilities (one hospital and one MCH) had ad hoc waiting shelters on their own initiative. The number of women using the facilities per month ranged from two to 75 (mean = 18). No evaluation has been conducted. Central South Somalia 2.7.13

EmOC

Most EmOC facilities in the Central South Zone (CSZ) receive some kind of support from NGOs or UN agencies. Most facilities are located in the population-dense areas of the coast. Private facilities are located in urban areas only. For a comprehensive list of facilities providing obstetric care in CSZ, see Annex H. For the CSZ, no similar comprehensive needs assessment has been done. There are currently at least 16 facilities offering CEmOC pr. Jan 2009 (see Annex H). With a population of 4.8 million, this gives 1.7 facilities/500,000 population, i.e. more than the minimum UN indicators. This number is likely to have been higher before 2008 due to NGO evacuation of supporting expatriate expert staff (surgeon or obstetrician). The same facilities now function as BEmOC + with blood transfusion possibilities. Concerning geographical distribution, the regions of Gedo, Bay, Bakool and Middle Juba now seem to be lacking a CEmOC facility, whereas in the other regions there is at least one working CEmOC facility and in some regions (Banadir, Middle Shabelle, Lower Shabelle) there are several. With a population of 4.8 million, the CSZ would have a minimum need of 38 BEmOC centres. Although it is likely that a few more facilities exist that can offer BEmOC than we have been able to register (12), there are considerable unmet needs compared to UN minimum standards. Having more CEmOC centres can to a certain degree compensate for the lack of BEmOC, but we then encounter inequity in geographical coverage as most CEmOC centres are in urban areas. Altogether, 29 centres can offer EOC but with a marked concentration in urban and coastal areas. BEmOC centres are often not located close to CEmOC, and there is no system linking the facilities, hampering timely referral. 2.7.14

Utilization of services

The utilization pattern is highly variable across facilities in the CSZ. Looking at NGO-supported district hospitals, these typically have 100-200 births per year, with a higher rate of complicated deliveries than in the NWZ26. For

26

Data from GHC, COSV, MSF.

48

CEmOC centres, this is a very low number to be able to sustain CS and supportive functions with specialized personnel around the clock. For 2007, the hospitals supported by COOPI/COSV/CISP in CSZ (Merka, Brava, Eldere, Harardere, Jowhar) all had between 107 and 250 deliveries per year, corresponding to less than one delivery a day. Concerning proportions of obstetric complications, this is highly variable. For example, in 2006 Merka Hospital had 189 admissions for delivery, where 66 women (35%) underwent CS or assisted vaginal delivery. This corresponds to around one to two CS per week. In Luuq and Garbahaarey hospitals in Gedo region, an average of one to two CS were conducted monthly during the first half of 2008. In general, even supported facilities have relatively few admissions of obstetric complications, and are not working to their full capacity. 2.7.15

Quality of care and other issues particular to the CSZ

There has been no systematic assessment of the quality of EmOC in the CSZ. With regard to qualified professionals for obstetric surgery, attracting qualified or practising surgeons or obstetricians remains difficult. Even if staff can be found, clan issues compromise mobility in the CSZ as members of certain clans can often not work in areas not inhabited by their own clans, due to mistrust and security issues. In other areas where two competing clans do not accept jobs being given to either, a solution for some NGOs has been to import whole surgical teams from outside the clan structure (e.g. staff of Bantu ethnicity). There is competition with the private market, as in some areas qualified midwives prefer to work in the private sector due to payment of up to US$ 15 to conduct a home delivery. Several NGOs expressed a desire to keep CS rates low, due to worries of sustainability and uncertainty of access to CS services at next birth. Some NGOs thus reported performing a CS only for maternal indications. CS rates were most often kept low (5-15%). This might be too low taking into consideration the referral status of the facilities, meaning population CS rates will be well under the recommended level, at the expense of foetal morbidity and neonatal mortality. 2.7.16

User fees

Private clinics charge for maternity services. Normal delivery care is most often free in NGO-supported facilities. Many NGO facilities offer free emergency CS, whilst others charge fees but have some kind of exemption policy. Some will charge for elective CS. User fees for a CS can range between US$ 100±400 (pers comms. with NGOs).

49

2.7.17

Referral mechanisms

There are no appropriate referral systems in place between facilities in CSZ. Many NGOs work without a realistic referral (>3-4 hours transport) to a CEmOC centre, or even BEmOC centres. This means that MCH/HC might function as a normal delivery point, but with many hours to an EmOC facility if complications arise. Some NGOs arrange and pay transport and pay the fee for CS (or other major obstetric intervention) in the referral private or public facility. 2.7.18

Vouchers

Most NGOs did not have experience with prepaid voucher schemes beyond the referral mechanisms mentioned above. Most NGOs offer free facilitybased delivery services (normal delivery point) and some are piloting incentives for facility-based births such as cash or free baby-care package (clothes, hygiene items, etc)27. 2.7.19

Maternity waiting shelters

None of the interviewed NGOs or UN bodies in the CSZ had direct experience or plans for maternity waiting shelters. A financing model, organization and potential impact in the CSZ remains largely unexplored. 2.7.20

Conclusions

Emergency obstetric care leaves a lot to be desired in Somalia. There is a crucial lack of BEmOC centres across all zones, and most CEmOC centres are highly underutilized. Poor accessibility due to long distances, insecurity, lack of transport and high user fees, are part of the problem. Lack of supplies, trained staff and effective management leading to low quality of services and low trust in health facilities among the population, causes underutilization even where services are accessible. Although some health centres function as normal delivery points, none can handle the complete range of BEmOC-functions and thus do not contribute to EmOC service supply. Among gaps to be addressed an obvious priority is to improve volume and quality of EmOC centres. Existing centres can be modified. Services must be affordable or free, and referral systems must be developed. Considering the huge expenses of keeping EmOC and especially OTs operational around the clock, production per unit has to increase in order to be financially efficient. Unexploited potential lies in making health staff work longer hours for the public sector, but this have to be accompanied by radical changes in supervision, incentive model and structure. The lack of any coverage of maternity waiting shelters is a definite gap especially concerning the rural and nomadic populations, in that

27

Experiences from MSF, IMC, MDM.

50

decentralization is difficult to obtain for the intermediate future, taking constraints in human resources and finances into consideration. Increased numbers of qualified midwives as well as MDs with obstetric skills, including CS, are needed to staff the EmOC centres.

2.8

Neonatal and postnatal care

Box 2.2 UN process indicator Neonatal care: Indicator 7: Neonatal resuscitation

Table 2.10 Available indicators (by zone and source) Perinatal Mortality Rate

81/1000

WHO 2007

Neonatal Mortality Rate

41-47/1000

MICS 2006/WHO

27% of EmOC facilities in NWZ

UNICEF/UNFPA 2006

Neonatal resuscitation with mask and bag performed last 3 months

24% of EmOC facilities in NEZ Neonatal tetanus protection

26%

MICS 2006

Timely initiation of breastfeeding

26%

MICS 2006

Neonatal deaths comprise only around half of total perinatal mortality, showing that a high number of babies die intrauterine or intrapartum due to poor pregnancy and delivery care. 2.8.1

Early neonatal care

Early professional neonatal care is provided by midwives, doctors, auxiliary nurses and community health workers at all levels (see Table 2.12). According to the Essential Package of Health Services, the role of the community health worker in neonatal care can be significant. The extent to which TBAs attending to births provide early neonatal care is unknown, but the topic is included in most TBA training curricula. Concerning Indicator 7, neonatal resuscitation is not performed in all EmOC facilities in the north. We have no numbers from the south. Only 26% of neonates are protected against tetanus by maternal immunization, indicating poor ANC coverage. Timely initiation of breastfeeding is low due to the tradition of throwing away the colostrum. The majority breastfeed at some point, but exclusive breastfeeding (of infants between 0-5 months) is only 9% as a result of the common practice of mixed IHHGLQJZLWKFRZ¶VPLONWHD and water.

51

For advanced intensive neonatal care, we have little data. During the assessment in 2006, 11 hospitals (six in NWZ and five in NEZ) had the services of a paediatrician. 2.8.2

Quality of care

Table 2.11Routine performance of potentially harmful practices28 Milking of the cord

55%

UNICEF/UNFPA 2006 (NWZ+NEZ)

Bathing baby soon after birth

51%

UNICEF/UNFPA 2006 (NWZ+NEZ)

Newborn suctioning

53%

UNICEF/UNFPA 2006 (NWZ+NEZ)

Artificial rupture of membranes

50%

UNICEF/UNFPA 2006 (NWZ+NEZ)

In EmOC facilities, there are widespread routine ineffective or potential harmful procedures, such as milking of the cord (55%), bathing the baby soon after birth (51%), newborn suctioning (53%) and routine artificial rupture of membranes (50%). Concerning newborn care at health post and community levels, there are major gaps in information concerning prevalence of the different elements of care as defined by WHO (see Table 2.12). Table 2.12 WHO Essential Newborn Care Package Element of Care 1. Cleanliness: clean delivery and clean cord care for the prevention of newborn infections (tetanus and sepsis) 2. Thermal protection: prevention and/or management of neonatal hypothermia and hyperthermia 3. Early and exclusive breastfeeding

Source: WHO (1996b)

Communitybased care (CHW)

Care at Health Post

BEmOC/Health Centre care

X

X

X

X

X

X

X

X

X

4. Initiation of breathing, resuscitation 5. Eye care: prevention and management of ophthalmia neonatorum 6. Immunization (BCG, Oral polio, Hepatitis B) 7. Management of newborn illness 8. Care of the preterm and/or low birth weight newborn

X X

X

X

X

X

X

X

X

X X

28

These procedures were routinely practiced in the past but have been shown to be of no benefit, or potentially harmful.

52

2.8.3

Conclusions

Compared with the WHO Essential Newborn Care Package, there are significant gaps in the quantity and quality of newborn care at all levels in Somalia. The most significant gap in interventions at health centre level is the insufficient practice of initiation of neonatal resuscitation, which can save newborn lives through simple means. The lack of syphilis-screening of pregnant women is almost ubiquitous. Attending birth staff are not aware of or trained in the special needs of the neonate, whilst still spending time and resources on outdated and potentially harmful practices. At the community level, many elements of the essential newborn care package have still to be introduced.

2.9

Antenatal care

Table 2.13 Indicators Antenatal Care Coverage (one visit)

26 %

MICS 2006

Percent pregnant women with at least two doses of Tetanus Toxoid Immunization Pregnant women given Vitamin A

26.3%

MICS 2006

4-25%

UNICEF 2008

2.9.1

ANC at health centres/MCH

ANC services are presently offered by MCH-clinics, some hospitals and a few health posts, as well as private practitioners in urban centres. According to the new WHO guidelines, three to four focused ANC visits are considered adequate for uncomplicated pregnancies (Carroli et al, 2001). The core purpose with ANC is to tie women to the health services and provide preventive services (e.g. health education and nutritional counselling, TTvaccination, vitamin A and iron-folate supplementation, de-worming and intermittent malaria prophylaxis in endemic areas). ANC will also screen for high-risk pregnancies according to medical history or current pregnancy complications (STI, previous pregnancy complications, pre-eclampsia, severe anaemia) that should be referred to a higher level in late pregnancy or at onset of labour depending on condition. A number of NGOs or UN agencies support individual MCH structures with rehabilitation, equipment and drugs. UNICEF supports 239 MCH clinics via NGOs throughout Somalia with MCHkits every two months, has donated delivery beds for many of them and collects monthly data. NGO-supported facilities are more likely to have supervision and monitoring in place on the ground. A list of which NGOs work in MCHs in the different zones is included in the overview table in Annex I. MoH-run MCHs are supposed to be open between 07h30 ± 13h00, six days a week (Sat-Thurs). In reality this is rarely the case and facilities tend to be

53

open for a couple of hours only, whereupon staff tends to leave for other commitments. Some NGO-supported MCH/HC are open until 14.00. Very few have 24/7 services. The staffing pattern of a MCH is heterogeneous, as are qualifications of staff. Some bigger facilities can have one to two qualified midwives, two to three auxiliary midwives and 10-15 associated TBAs on their staff lists. Smaller facilities have two to three auxiliaries and possibly a qualified nurse or midwife. Shortages of qualified staff are especially common in rural areas. Data collection (UNICEF Somalia, 2008) shows that utility of services vary a lot; this is thought to relate to drug supply, as the demand for curative services is much higher than preventive. As composition of drug kits are not based on consumption, shortages of high turnover drugs can be expected. UNICEF kits are currently under review (Feb 2009). UNICEF supports the Ministries of Health in being able to supervise facilities, assist with training, tools and funds for transport. Despite this, supervision is fragmented and irregular. 2.9.2

ANC at health posts

Seventy percent of HP assessed in NWZ reported performing some ANC functions such as giving drugs to pregnant women, whereas 20% of those in NEZ did the same (UNICEF/UNFPA Somalia. 2006). The complete ANC package is not performed and the number of visits per facility in general is low. 2.9.3

Antenatal care coverage

The MICS 2006 show that countrywide an average of 26% of pregnant women receive at least one antenatal visit during their last pregnancy. Of these, the median number of visits is two. Although of low coverage given the Somali context, it is an opportunity to reach out with preventive services to women. Table 2.14

Percentage of pregnant women receiving antenatal care among

women aged 15-49 years who gave birth in two years preceding the survey

Source:

MICS 2006

Number of antenatal care visits during pregnancy Mean number of visits No visit One visit 2-3 visits 4+ visits among women who received antenatal care Zone NWZ NEZ CSZ Residence Urban Rural

60.4 69.8 70.6

9.6 8.4 7.9

19.6 16.0 16.3

10.3 5.8 5.2

2.6 2.1 2.0

49.3 79.4

11.0 6.8

29.5 9.7

10.2 4.1

2.4 1.9

54

There are marked urban-rural differences in that 79.4% of women in rural areas have no antenatal visit compared to 49.3 in urban areas. In the NWZ women have the highest average number of ANC consultations (2.6) followed by NEZ (2.1) and CSZ (2.0) (ibid.). There is a major access problem for women in rural areas. In addition the likelihood of receiving ANC one or more times during pregnancy varied with wealth indices, in that only 12.8% of women in the poorest quintile received any ANC, compared to 55.5% of women in the richest quintile29

Table 2.15 Antenatal care provider Source: MICS 2006 Medical doctor Zone NWZ NEZ CSZ Rsdnce Urban Rural Nomadic

Person providing antenatal care Nurse/ Auxiliary TBA Relative midwife midwife / friend

Other

No antenatal care received

Any skilled prsnl*

27.9 12.4 17.3

2.2 10.3 1.9

1.7 2.9 5.2

1.9 2.8 2.6

0.2 0.0 0.4

5.6 1.8 1.9

60.4 69.8 70.6

31.8 25.6 24.4

34.1 10.9 7.8

5.2 2.0 0.5

6.2 3.2 2.2

1.6 2.9 3.4

0.3 0.3 0.7

3.3 2.5 1.5

49.3 78.2 83.8

45.5 16.1 10.6

Surprisingly, most women receive ANC from a medical doctor across all zones, followed by a nurse/midwife, suggesting that ANC services are likely to be highly privatized. TBAs are only rarely involved in antenatal care. The nomadic population has the poorest coverage with only 16.2% of women receiving any antenatal care. Table 2.16

Zone NWZ NEZ CSZ Residence Urban Rural Nomadic

Reasons for not attending ANC

Source: MICS 2006

Reasons for no antenatal care check-up

No antenatal care received

No need to see anyone

Not convinced by assistance

Not financially able

Difficulty reaching place of care

No medicine/ care available

60.4 69.8 70.6

60.8 49.2 37.6

12.6 2.1 0.8

18.0 24.5 26.9

7.2 31.0 38.8

3.4 6.9 3.8

49.3 78.2 83.8

56.9 60.4 46.9

4.1 2.2 5.2

22.0 16.6 24.6

20.8 22.3 28.1

2.1 3.4 6.7

The major reported reasons for not attending antenatal care differed markedly across the zones. For the CSZ the major reasons were difficulty in reaching place of care (38.8%) and no need to see anyone (37.6%), for NEZ 29

MICS 2006.

55

the major reasons were no need to see anyone (49.2%) and difficulty in reaching place of care (31%). In the NWZ 60.8% reported no need to see anyone, followed by not financially able (18%). 2.9.4

Quality of care

For those reaching ANC services, the quality of care is poor and a missed opportunity. According to MICS only 14.2% of women that gave birth during the last two years had a blood test taken during the pregnancy. Twenty-one percent had blood pressure measured and 9% had urine analysis performed. These numbers are low considering that 26% of women at some point make the effort to come for ANC. According to UNICEF data from MCHs, looking at services provided at the ANC visit only 15% of pregnant women get adequate TT-vaccination (TT2+), and 4-25% of women get Vitamin A supplementation. Only half of ANC attendees recall being informed of pregnancy complications30 Breaks in supplies, absence of qualified staff, short working hours and weak supervision are some of the factors believed to be responsible for low quality of services. Although syphilis screening of pregnant women to prevent congenital syphilis is considered a cost-effective intervention in eastern Africa, only in exceptional cases was this offered at HC-level, whereas most hospitals would offer the service. Somaliland There are low utilization of ANC services, with a coverage of 1st ANC visit varying between 14% (Awdaal) to 45% (Hargeisa). Coverage of 1st PNC visit is highest in Awdaal (9.6% and lowest in Sahil (2.2%)31. Average numbers of ANC-visits at MCH level are three in Hargeisa and Sool, two in Awdal and one in Sahil, Togdheer and Sanag, with a national (Somaliland) average of two. A recent survey in Togdheer region in Somaliland showed that 21% of pregnant women received ANC, and received on average three visits during their last pregnancy32. The Somaliland Immunization Coverage Survey Report33 found that 31% of mothers had made at least one ANC visit during their last pregnancy.

30 UNICEF Somalia (2008). National Primary Management Information Report Somalia and Somaliland 2007. 31 Ministry of Health and Labour Somaliland (2006). Annual Health Report 2006. 32 Save the Children UK (2008). Health Baseline Survey for Togdheer Region, Somalialand. 33 UNICEF/WHO Somalia (2008). Somaliland Immunization Coverage Survey.

56

2.9.5

Quality of care

According to the Toghdeer survey above, 45% of attending women had a blood test taken, 78% had blood pressure taken, 40% had a urine analysis performed, 20% had a TT-vaccination and 28% were given iron supplementation. Fifty-two percent were informed of pregnancy complications. The coverage of TT2+ vaccination shows marked urban/rural differences (76% versus 40%34). 2.9.6

Clean delivery kits

An activity at MCH level is the subsidized sale of clean delivery kits to pregnant women. The UNFPA kit consist of soap, a square meter of plastic sheet, a razor blade, string for tying the umbilical cord, a bag, gloves, a 1 m x 2 m white cotton cloth and a pictorial instruction sheet. The kits are delivered by UNICEF and UNPFA to many supported MCH/HC, as well as to hospitals and IDP camps and are highlighted by newsletters and website as a core activity at UNFPA/WHO/UNICEF35. Clean delivery kits (CDKs) have been implemented by many partners in Somalia, but not always as part of a concerted effort within maternity care. Monitoring and evaluation is scarce and there is little operational knowledge of impacts. Assessments of distribution of CDKs as a single intervention on maternal or neonatal health in similar settings have shown disappointing results36. Experiences from other settings show that CDKs should not be delivered in a way that encourages home births in general, or give the impression that a CDK will guarantee safe delivery. There is also a need to investigate the cultural acceptability of the content. Presently the kits contain white material intended for wrapping of the baby after delivery, whereas in many cultures white cloth is usually only used for covering dead babies and is therefore not culturally acceptable to pregnant women. Concerning health facilities conducting deliveries, these should rather be supplied with the necessary basic equipment to be able to conduct a clean delivery (sterilizer, surgical instruments, sterile rubber band for umbilical cord, etc.). 2.9.7

Birth preparedness

An activity often advocated at community level is to promote birth preparedness; i.e. community members and pregnant woman are given 34

UNICEF/WHO Somalia (2008). Somaliland Immunization Coverage Survey. 81)3$1HZVOHWWHU³Samofal´1RYHPEHU 36 There is little scientific evidence that, as a single intervention, use of CDKs is necessarily the most appropriate way of ensuring that caregivers and birth attendants pay sufficient attention to antisepsis. There is little evidence that kit use alone impacts umbilical cord infection or neonatal mortality rate (Zulfiqar et al. 2005). Clean delivery kits have neither been shown to reduce incidence of maternal sepsis nor endometritis. Research shows that CDKs only have a role as part of a concerted strategy. Behaviourchange communication strategies to promote clean delivery practices, including clean cord cutting, should be implemented in tandem with the kits. Although each kit is inexpensive, the assembly and distribution of WKRXVDQGVRINLWVDUHQRW7KHNLWVE\WKHPVHOYHVDUHQRWD³PDJLFEXOOHW´DQGFDQHDVLO\VHUYHDVD detour to maternal health, consuming human and financial resources on the way (Maine, 2007). 35

57

advice about where to deliver and what to do in the event of complications. This approach has been promoted without evidence that it actually helps, and some evidence now suggests that providing messages on birth preparedness does not change behaviour. One flaw in this strategy is that it assumes that people do not use health facilities because they lack information or planning skills, whereas the major deterrents are usually the high cost and poor quality of services, and the fact that nearby facilities are not functioning. 2.9.8

Conclusions

The coverage and frequency of ANC is low, with considerable drop-out rates and limited awareness of benefits. Accessibility varies over zones and is very limited for the rural and nomadic population, as well as for the poor. Even when women make the effort to come to the services, quality is poor and can be traced to inadequate staff qualifications and performance, breaks in supplies and poor management. These constitute a major missed opportunity. Lack of linkages and physical proximity for referral to CEmOC centres seriously hamper program efficacy. Comprehensive rehabilitation in functioning of health centres is necessary to improve services. 2.10 Postpartum care Table 2.17

Indicators/issues

Postpartum Vitamin A supplementation

2.10.1

8.7%

MICS 2006

Postnatal care provider and coverage

The contents of postpartum or postnatal visits are not in any way standardized in Somalia and most studies have registered postnatal care as any contact with a health care provider, some including TBAs, making comparisons difficult. Table 2.18

Postnatal care provider No postnatal care received

Zone NWZ NEZ CSZ Residence Urban Rural Nomadic

Source: MICS 2006

Person providing postnatal care Government doctor

Private doctor

Nurse/ midwife

Auxiliary midwife

87.6 89.7 87.2

1.8 2.5 2.6

4.9 3.7 3.0

1.2 0.8 0.5

1.4 3.2 5.6

82.5 90.1 92.3

3.7 1.7 1.7

7.2 1.4 1.2

1.3 0.5 0.0

3.7 4.9 4.3

Table 2.18 shows that of women who had given birth during the previous two years, an average of 88% did not receive any postpartum care, with little

58

variation over the zones. Even among the urban population only 18% received postpartum care. Of women with a birth during the last two years, by the time infants were eight weeks old only 8.7% had received Vitamin A supplementation. The major reported reasons for not attending postnatal care were no complications (56-66%) or services not available (15-23%). When women were asked whether they experienced health problems after delivery, the most commonly cited self-stated problem was fever (52%) and mastitis (41%)37. Somaliland In Toghdeer38, 25% of women reporting having received postnatal care during the birth of the last-born child, but content is unclear and therefore whether they meet criteria for this to be qualified as a postnatal care visit. Of women receiving postnatal care, 57% received it from a TBA. It is clear that women experience and report major health problems during the postpartum period, but only few seek medical help. Of these, not all receive routine standard preventive measures such as vitamin A supplementation. This is a major missed opportunity.

2.10.2

Conclusions

Awareness of the importance of postnatal care is very low among Somali women, reflected in that only 10-12% of them receive any postnatal care with little variation across zones and urban/rural axes. TBAs are the main provider of postnatal care and content of care thus provided is highly variable and not according to internationally-accepted standards. The numbers of women and neonates receiving timely qualified postnatal care might therefore be even lower.

37 38

MICS 2006 Save the Children UK (2008). Health Baseline Survey for Togdheer Region, Somalialand.

59

2.11 Family planning39/birth spacing Table 2.19

Indicators 6.2-6.7

MICS 2006/WHO

Age specific fertility rate (women 15-19 years)

123/1000

MICS 2006

Crude birth rate

43.2 ± 45

UNDP 2007 / UNFPA 2005

Contraceptive Prevalence Rate (women 15-49y)

15 %

MICS 2006

Modern Contraceptive Prevalence Rate (women 15-49y)

1%

MICS 2006

Modern Contraceptive Prevalence Rate (men 1549y)

No data

-

Unmet need for contraception

26.2 %

MICS 2006

Total Fertility Rate

The desired number of children in Somalia is high, contributing to the high total fertility rate of 6.7. Contrary to other countries in the region, there is no marked difference in TFR between urban and rural communities (TFR urban 6.0 vs. rural 7.1). It is a common concern that modern methods of FP may not be consistent with Islam40. Permanent methods such as tubal ligation or vasectomy are ZLGHO\FRQVLGHUHGXQDFFHSWDEOHEHFDXVHLWGRHV³SHUPDQHQWKDUP´WRD person. Reversible FP methods were available and used in certain areas prior to the present existing political climate. Examples of successful approaches before 2000 include both urban clinics and rural community-based services where FP were integrated with prenatal services, as well as community based seminars and training of health staff including drug retailers (Abdelmohnsen, 2006). In Somaliland a public FP program was in place from 1995 to 2002 at MCH-level. Male condoms are controversial as they are seen as being connected to infidelity and immoral behaviour. Public burning of condoms has happened occasionally in several zones. Recently elements from the political group Al Shabaab have condemned the promotion and use of male condoms. In general FP seems to be a politically sensitive issue more than a cultural one. 2.11.1

Demand and uptake of services

Overall demand and uptake of FP services is low. Fifteen percent of women use any method, including traditional or natural periods and only 1% use a 39 Contraception to prevent unwanted pregnancies, space children or limit the total number of children will here be referred to as family planning (FP). Emergency contraception will be considered included. 40 Islamic opposition to FP is based in the belief that God should determine the number of children, as well as a belief that it is a Muslim duty to perpetuate the nation (Umma). Islamic support of FP on the other hand, is based on contraception as only a means, and that the results are in the hands of God. Verses from the Quran highlight the importance of maintaining family harmony as well as God not wishing to burden believers, both implying that too many children will compromise family well-being.

60

modern method41. Of the 1% that use modern methods, pills are the most common (0.8%) followed by injections of medroxyprogesterone acetate (0.2%) and IUD (0.1%). Condom use was at 0.0% for contraceptive purposes. Of traditional methods, lactation amenorrhea is among the mostused methods at 13% among married women. As the exclusive breastfeeding rate for children between 0-5 months is only 9%, there is a low protective effect even for women using this method. Qualitative surveys have established that FP is increasingly recognized by women, especially in urban areas, and that men as decision-makers appear to be the biggest obstacle to the uptake of modern FP services. Misconceptions as to modern methods regarding intent, safety, and efficacy are widespread. Despite low use of condoms among women for contraceptive purposes (0.0%) (MICS, 2006), qualitative surveys show demand for condoms for protective purposes but within confidential delivery-systems. In a study among urban IDPs in Somaliland, only 3% of contraceptive users had received it from a pharmacy, 75% had received the services from a MCH and 1% from a private hospital. Asked where they would seek services if the need arose, 75% of women would seek FP at MCH level, 20% would go to a hospital and 1% would go to a pharmacy (Health Unlimited Somalia, 2008). 2.11.2

Offering of services

When it comes to the current attitudes of many NGOs, a restrictive attitude prevails as to initiation or scaling up of services. Some emphasize cultural taboos, whereas others emphasize the present political situation more than the cultural context as a difficult environment for initiation or scaling up of FP services. Most NGOs in the CSZ where Al Shabaab is in charge, view scaling up or even offering of the services as a potential security threat. At HC level, conditions vary from no contraceptives to a range of the most modern FP methods (pills, condoms, injections). UNFPA has been the main supplier of kits. In the NWZ and NEZ, kits are mostly delivered through MoHs which does not always translate to adequate supply, at least not at HC level. Data on consumption of FP commodities at facility-level are lacking. Some agencies have a policy of no injectables in the clinics as the staff are not trained. At hospital level, surveys show low numbers of FP-consultations. IUD, injectables and implants are often not available. UNFPA Kit No. 4 contains items for injectable contraception, but delivery is not comprehensive and goes through MoHs in several zones who do not seem to prioritize continuously uninterrupted supply. There is a low acceptance of tubal ligation and vasectomies. FP services are in general not exempted from user-fees.

41

MICS 2006

61

Systems for monitoring and evaluation of prescription and use of contraceptives are not in place. Where assessed, knowledge of health staff of FP issues is limited to areas where special training has been conducted. 2.11.3

Role of private sector

In general, in private health facilities the numbers of consultations for family planning seem to be low. A recent assessment in Somaliland showed that many private pharmacies stock a selection of FP methods and that most had received requests, pointing to an existing public demand42. In a survey of mainly unsupported health facilities in Somaliland in 2008, at referral hospital level injectable contraceptives were not available despite being perceived as the most popular contraceptive among clients (UNFPA/UNAIDS/WHO Somalia, 2008). A study of 261 private pharmacies in Hargeisa by MoHL in 2008 showed that 40-50% of pharmacies also offer consultation services. Around half of them are owned by qualified or auxiliary nurses or midwives, around 20% by doctors and only six businesses were owned by pharmacists. Around half of the pharmacies had a nurse as supporting health staff, around 10% doctors, and only three businesses had supporting pharmacists. Most pharmacies have an injection room. A vial of Depo Provera costs around US$ 1. The extent to which pharmacies currently supply adequate FP services in the other zones needs further assessment. 2.11.4

Social marketing of FP commodities

In a number of countries, social marketing of RH commodities has been introduced with success. No such initiatives are presently in place in Somalia. Exploring potentials for marketing certain commodities e.g. male condoms through pharmacies, could be useful. Factors working against social marketing are low awareness and mistrust of modern methods, combined with cultural restrictions on public advertisement for FP commodities which makes delivery through a comprehensive public maternal health program more suitable. 2.11.5

Promotion of services

The active promotion of FP services at community or facility level was not reported by any NGO in the three zones. Promotion of FP at community level is generally lacking, even by leading UN agencies. Individual counselling is conducted by some NGOs upon request. TBAs are not considered to have any role or influence in the area of FP (UNICEF Somalia, 1998). 2.11.6

Unmet need

Unmet FP need among women of reproductive age is estimated to 26.3%43. Younger women who want FP for child-spacing purposes constitute the 42 43

Personal communication consultant UNICEF 2008. MICS 2006

62

majority (21.4%), but there is also an unmet need for child-limiting among older women (4.8%). 2.11.7

Conclusions

There are unmet needs for FP, both for avoiding unwanted pregnancies, birth spacing and/or limiting the number of children. These needs are not being comprehensively addressed at the moment. Existing FP activities are sporadic and there is no existing national plan. FP commodities are delivered mostly to hospitals and, except for male condoms, supplies do not seem to trickle down to health centre level. Due to perceived political, religious and cultural barriers the issue of FP remains one of the most serious gaps in Somalia, considering the potential impact FP could have on preventing a large number of maternal deaths.

2.12 Obstetric Fistula Table 2.20 Indicator Incidence obstetric fistula/y

1-5 / 1000 deliveries

270-810 new cases

Obstetric fistula is the most serious consequence of obstetric morbidity, but can also develop after gynaecological surgery and sexual assault. FGM is not a common direct cause of fistula in Somalia. The exact prevalence rates in Somalia are not known, but the estimated obstetric fistula incidence for Somalia extrapolated from figures for East Africa is 1-5/1,000 deliveries (UNFPA Geneva, 2005). Given a crude birth rate of 45/1,00044 (with a population estimate of eight million) this gives a range of 270-810 new cases per year. 2.12.1

Fistula prevention

Prevention of the majority of obstetric fistula can be accomplished by universal access to and timely referral to EmOC. A few cases of fistula arise from complications to Caesarean sections, abdominal and vaginal hysterectomies and after sexual assault, but in Somalia the occurrence is largely related to obstructed labour. Improved access to EmOC will lower the number of new cases and remains a priority in the work against obstetric fistulae. Primiparas are the main target, and they should ideally be delivered at a BEmOC or CEmOC facility. 2.12.2

Fistula treatment

Successful surgical repair depends upon availability of a skilled surgeon with continuous experience of handling a high number (10-20) of cases/year. Many women have undergone several surgical procedures by incompetent health staff, making a successful repair more difficult. Success rates of fistula repair depend on proper and careful case-selection, high-volume per surgeon 44

UNFPA Mission Report no. 38.

63

and his/her surgical expertise as well as on strict compliance with postoperative care. 2.12.3

Progress addressing fistula

A needs assessment was conducted in 2005 and treatment centres were identified and initiated. An assessment in 2005 in Northern Somalia found 10 hospitals, six in NWZ and four in NEZ with someone trained to do fistula repair. All ten of them reported at least one repair in the last year, but no information on volume per surgeon, which is an important criterion for quality and success. During 2007 and 2008 the establishment of fistula surgery at two locations was finalized with external support from UNFPA and NGOs. These were: NWZ: Boroma Regional Hospital: 42 patients operated on in 2008 with 85% success rate. NEZ: Galcayo Medical Centre: 37 patients operated on in 2008 with 85% success rate. With the lowest incidence estimate of 1/1,000, the activity of these two centres is only enough to cater to around a third of new cases. The volume of fistula surgery being conducted in non-specialized centres is not known and there is spill-over across the Ethiopian border where patient flow might go both ways. Fistula camps with a travelling regional surgeon have been carried out by NGOs in the CSZ. 2.12.4

Costs

Direct cost estimates are US$ 300/surgical repair with around 80-90% success rate (pers.comm. UNFPA, 2008).The costs of prevention of a case of fistula are complex and presently unknown in Somalia, but taking into considerations the loss of DALYs in the primary birth, prevention will remain a more cost-effective intervention. 2.12.5

Conclusions

Demonstrated gaps in EmOC services in Somalia are the cause of the majority of fistulas in Somalia. There are estimated to be considerable unmet needs also on the curative side. Considering the state of EmOC in Somalia and the human suffering and expenses in conjunction with the initial birth causing the fistula, often including a stillborn baby, prevention of fistula must be a priority.

64

2.13 Post-abortion care Table 2.21 Zone

Abortion status Somalia Legal status of abortion

NWZ

Prohibited according to Penal Code of 1962

NEZ

Prohibited, except when ZRPDQ¶V life in danger (Puntland Constitution, 2001)

CSZ

Prohibited according to Penal Code of 1962

2.13.1

Regulation of termination of pregnancy

Owing to the breakdown of central government in Somalia, current abortion law and policy are unclear. Before the breakdown of governance, performance of abortion in general in Somalia was prohibited by the Somalia Penal Code of 1962. According to Puntland¶s constitution of 2001, termination of pregnancy in Puntland is illegal unless the ZRPDQ¶V life is in danger45. 2.13.2

Extent of the problem

The exact extent of induced termination of pregnancy, safe or unsafe, in Somalia is unknown. In a 2000 KAP survey on reproductive health, 2% of women of reproductive age reported having sought termination of pregnancy. Of these a majority are likely to have been conducted in an unsafe environment. Fifteen percent of pregnancies are likely to end in spontaneous termination before gestational week 20 and a proportion of these (normally 5-10%) will be incomplete or complicated with infection, requiring D&C or MVA-procedures alongside correct medical treatment. During 2007, 1,200 women sought services at HC level for abortion or miscarriage, which represents approximately 9% of the expected cases (UNICEF Somalia, 2008). Most HC today do not have the capacity to deal with complications of abortion. Hospitals reports include abortion as a main reason for admission to gynaecological or surgical wards, but no reliable data on percentage of admission to GYN/OBS wards exist currently. Regarding the fact that women already seek services at facilities at several levels, there is a clear unmet need for comprehensive post-abortion services at both HC and hospital level. This includes post-abortion contraceptive counselling.

45

Article 11 B. Puntland Health Act law No.6 Article 18-3 Puntland Constitution.

Office of the President, Puntland State of Somalia

65

2.14 Prevention and treatment of STI/HIV-AIDS Table 2.22

Indicators

HIV-prevalence among Pregnant Women

0.9%

WHO/UNAIDS 2008

Ever heard of AIDS

57.1% (women) 71.3 % (men) 11.4% (women) 24.1% (men) 6.0% (women) 6.7% (men)

HIV/AIDS KABP 2004

Genital tract discharge last 6 months

4.7% (women) 4.4% (men)

HIV/AIDS KABP 2004

Had treatment for STI*

89.2% (women) 93.3 % (men)

HIV/AIDS KABP 2004

Knowledge that condom prevents transmission* Ever contracted STI

HIV/AIDS KABP 2004 HIV/AIDS KABP 2004

*of those ever heard of AIDS ** Of those who had STIs

2.14.1

STI

The current prevalence of many STIs in Somalia is unknown but believed to be relatively high. The three most common causes for visiting HCs for adults and children > 5 years in 2007 were pneumonia, STI/UTI and anaemia46. In 2004, 4.7% of women and 4.4% of men reported having had discharge in the past six months, whereas 6% of women and 6.7% of men had ever contracted a STI (UNICEF Somalia, 2004). In high-risk groups such as sex workers, STIs are common. A study of 155 sex workers in Mogadishu in 1991 showed 47% had active syphilis as judged by positive serologic markers (TPHA, VDRL and RPR test)(Ahmed et al, 1991). A rural study on hepatitis B in 1985 showed increasing prevalence of HBV markers with age, from 9.7% in subjects less than 12 years to 68% in adults (Bile et al, 1991). Training on STI for health workers (WHO Syndromic Case Management) has been conducted in some areas in Somalia by WHO/UNFPA, mostly at hospital level. 2.14.2

HIV/AIDS

The prevalence of HIV in Somalia is estimated to be low. The latest estimated adult prevalence rate from UNAIDS/WHO is 0.5%( range 0.3 ± 1.0%) (www.who.int). The prevalence among pregnant women is 1-4.9% in some

46 81,&()6RPDOLD  ³1DWLRQDO3ULPDU\0DQDJHPHQW,QIRUPDWLRQ5HSRUW6RPDOLDDQG6RPDOLODQG ´

66

urban sentinel surveillance sites (Mogadishu, Hargeisa and Galcayo), and 00.9% in rural sentinel sites (www.who.int), with an average 0.9%. The number of facilities providing both antenatal care and VCT services are very few in Somalia, with a coverage of 0.0%. There are seven ARV sites in Somalia and 11 PMTCT sites47. Only 11 pregnant women living with HIV received PMTCT services in 2007, an estimated coverage of 1% (11/940 women). The year before, five women received PMTCT services (5/900 women) (www.who.int). 2.14.3

Conclusions

Contrary to available funding for other parts of the RH field, funding for HIV/AIDS prevention and awareness has been available. Despite this, uptake and coverage of the PMTCT program as shown, is low. This points to funding alone being unlikely to solve low uptake of services, and suggests that a health system rather than a vertical approach might achieve more. Fully integrating prevention and management of STI and HIV/AIDS with maternal and neonatal health services would bring vital resources and thus improve performance of both systems.

2.15 Medical response to survivors of sexual & gender-based violence (SGBV) In general, there is huge lack of awareness of the health implications of SGBV in Somalia, to the extent that some practices have been normalized. 2.15.1

Rape and sexual assault

There is little data on extent of SGBV in Somalia. Displaced women and returnees are particularly vulnerable to sexual exploitation and violence.

Few victims report rape due to fear of stigma, victimization or having to marry the rapist. 2.15.2

Domestic violence

The western definition of domestic violence is not readily transferable to Somali society. Although a husband may beat his wife or force her to have sex or physically threaten her, he may be acting within his rights according to Somali culture. :KLOHDZRPDQPD\QRWFRQGRQHKHUKXVEDQG¶VEHKDYLRXU she may also feel she does not have the right to contest it. Many Somali women blame the use of khat IRUWKHLUKXVEDQG¶VYLolent actions. After using the drug some men become quarrelsome and demand sex without regard for their wives¶ feelings. The extent of domestic violence remains undocumented.

47

WHO Somalia 2008

67

2.15.3

Activities

In 2007, 87 cases of rape were treated in Hargeisa Group Hospital (HGH) in Somaliland. In the first six months of 2008, 54 cases were treated. In three NGO-supported district hospitals in Gedo region (Luuq, Bullahawa and Garbahaarey) there were no cases of SGBV treated during the year of 200848. With the limited access to health facilities, there are likely to be extensive unmet needs for survivors of SGBV. Due to stigma, women are not likely to seek emergency services at facility-level. With regard to NGOs, only a few agencies offer the complete care package for victims of SGBV at HC-level (see Annex B for IASC guidelines), so overall care coverage is thus presumably very low. Post-exposure prophylaxis (PEP) for HIV, post-coital emergency contraception, also in the form of Mifegyne (which works for up to 14 days after intercourse), are the most frequently lacking components reported by NGOs. Other ongoing interventions in the field of SGBV, include training on medical management of SGBV survivors (UNFPA in 2008 in coordination with local authorities in Hargeisa and Baidoa.) while UNFPA has also performed distribution of PEP kits to health facilities. There has been an initiative by UNHCR/UNDP to open a SGBV-resource centre in an urban area (Hargeisa), but links and integration with other reproductive health services have not been established. The approach to victims of SGBV with integrated medical, law and protection-services have to be revised to fit the Somali context and to avoid duplication of services. 2.15.4

Medical complications of FGM

The prevalence of immediate and delayed complications to the procedure is unknown, but case reports of deaths due to immediate complications such as haemorrhage are not infrequent. Long-term consequences of FGM include cysts and abscesses, keloid scar formation, damage to the urethra resulting in urinary incontinence, pain during sexual intercourse, sexual dysfunction, menstrual pains, infections, bleeding and pain during Circumcision, and difficult childbirth. If the operation is conducted in unhygienic surroundings and/or using shared instruments, the victims are exposed to deadly infections like tetanus and HIV/AIDS (UNFPA/The World Bank, 2005). In HGH in Somaliland, around 10-15 women are seen daily in the gynaecological OPD for FGM-related complications, most of whom require medical treatment (Health Unlimited Somalia, 2008). As previously discussed, FGM types II and III are associated with increased risk of Caesarean section as well as adverse pregnancy outcomes (WHO, 2006a). 48

Data from Gedo Health Consortium.

68

The MoH Puntland has prohibited the practice of FGM by law49. Nevertheless, the percentage of women having undergone FGM is highest in Puntland (98.1% FGM, of which 93% were Type III) compared to the other zones50. FGM-awareness campaigns and activities have been conducted by different implementing partners in all three zones. There are informal and unconfirmed reports that the practice, especially in urban areas, is shifting from extreme to more moderate forms but it remains to be seen if this is a sustainable trend. On average 64.5% of women between 15-49 years believe the practice should continue, with marked variation by zone with 32% in the NWZ, 45% in the NEZ and 80% in CSZ (ibid). 2.15.5

Conclusions

SGBV is prevalent and partly normalized in Somalia, and due to cultural barriers the health system will only meet the tip of the iceberg. The coverage of quality health services, commodities and staff skills for comprehensive management of gender-based violence (including FGM-complications and rape) are low. A multi-sectoral response is needed to adequately address SGBV and is beyond the scope of this document (see Annex J).

2.16 Adolescent and youth reproductive health Table 2.23 Indicators/issues: Age at perceived first sexual intercourse (median)

15 years (women) 18 years (men)

HIV/AIDS KABP 2004

Age at perceived first marriage (median)

17 years (women) 20 years (men)

HIV/AIDS KABP 2004

Respondents agreeing that young people should be taught RH issues, including HIV

80%

HIV/AIDS KABP 2004

Ever heard of condoms (15-24 years)

24% (women) 40.9% (men)

HIV/AIDS KABP 2004

Ever heard of STIs (15-24 years)

42.8% (women) 55.8% (men)

HIV/AIDS KABP 2004

Ever contracted STI (15-24 years)

3.1% (women) 2.6% (men)

HIV/AIDS KABP 2004

Ever heard of AIDS (14-35 y)

89.6%

UNFPA 2008 (Puntland)

Ever heard of AIDS (15-24y)

66.5% (women) 71.0% (men)

HIV/AIDS KABP 2004

49 50

Article 11 A. Puntland Health Act law No.6 MICS 2006.

Office of the President, Puntland State of Somalia

69

2.16.1

Age of sexual debut and marriage

Perceived ages of sexual debut are 15 for women and 18 for men. Ages of first marriage are perceived to be 17 for women and 20 for men. There is evidence that the median age for first marriage is declining (UNICEF Somalia, 2004). Pregnancy out of wedlock is followed by severe punishment such as forced marriage, forced abortions and expulsion from family and community. Cases of unmarried teenagers getting pregnant are clouded in secrecy, denial and fear of disclosure, hence exposing the girls to sometimes fatal reproductive health risks (Health Unlimited Somalia, 2008). 2.16.2

Knowledge of RH issues

Sexual-reproductive health knowledge is poor especially among girls/women where only 25% of women have ever heard of condoms, and only 43% have ever heard of STIs. A study conducted in 2008 among urban young people between the ages of 14 and 35 in Puntland showed that 90% had heard of AIDS (UNFPA Somalia, 2008). 2.16.3 Youth-friendly RH activities Supportive adolescent RH policies are few; there is no enforced minimum age of marriage etc, little or no sexual and RH education in schools. Youth friendliness of RH services is poor, and youth-friendly clinics designed to meet their needs in a culturally acceptable frame are non-existent. Among urban youth in Puntland, 75% reported not to have access to free health services or facilities (ibid). A positive finding is that 80% of the general population acknowledge and accept the need for information of RH issues to the youth (UNICEF Somalia, 2004). 2.16.4

Conclusions

There are significant needs for improved reproductive health services for the youth, and the population seems to support their need for information.

2.17 Infertility and cancer of the reproductive tract organs 2.17.1

Infertility

The prevalence of primary and secondary infertility in Somalia is unknown. STIs are considered prevalent and it is likely that genital chlamydia and gonorrhoeal infections as well as genital TB are frequent causes of secondary infertility. The WHO Syndromic Case Management of STI has been established, but not in all facilities.

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With the current level of health services, the most effective prevention of infertility will be prevention and early treatment of STIs that have the potential to render men and/or women infertile. Barrier contraceptives are available, but there is a need for discreet delivery. 2.17.2

Cancer of the breast and reproductive organs (cervix, uterus, fallopian tubes, chorioncarcinoma)

In the current situation there is little available data on the prevalence of reproductive health organ cancers in Somalia. Screening of precancerous lesions in the cervix will be a possible intervention once health services have expertise and resources to deal with it. For the future, there are promising vaccination possibilities against carcinogenic types of HPV causing cervical cancer, but costs are presently prohibitive. Introduction of a vaccine will have effects on cancer-rates only several decades from now. At the moment, the lack of organizational and financial capacity of the health system makes a screening program unrealistic and not a priority. One-stop clinics with diagnosis and treatment of cervical dysplasia have proved valuable in similar settings, and will be a next step once the health system has the organizational and financial capacity.

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3.

Health work force

3.1

HR policy level

There is a department for human resource management in each of the three Ministries of Health of the three zones (see Annex K). Comprehensive HR development and management plans are non-existing at the moment, although there is some progress in Somaliland concerning standardization of cadres and payment scales. 3.1.1 Qualifications of health staff Qualifications of health staff in Somalia are a major problem, as few have valid certification papers. There has been no systematic attempt to categorize health staff according to qualifications, although a framework has been developed to do so (Beesley, 2008). No legal certifying body to qualify health professionals exists in any of the zones. Professional associations have been formed, however they have not yet become professional certifying bodies although there is current progress in Somaliland. There is no existing code of conduct for health professionals.

3.2

HR availability and production

There is a major shortage of professional health manpower at all levels. Even before 1991 health staff coverage was low, especially in rural areas. After conflict broke out, systematic education of health staff ceased and a substantial number of health staff left the country. The present health staff pool is small, aged and under-trained. Concerning reproductive health, there is a particular deficiency in trained midwives, surgeons, obstetricians and other staff with the manual dexterity to perform assisted vaginal delivery, Caesarean section and standard procedures for complications in childbirth. Specialized staff for reproductive health (midwives and doctors) comprise only 15% of the total workforce (see Table 3.1). Concerning numbers of staff per cadre, due to the lack of certifying bodies there are wide variations in estimates. The numbers below are the most recent estimates:

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Table 3.1 Estimated human resources for health by zone ± Public and Private (MoH, 2007) Sources: Primary Health Care Brief/SC/UK, WHO, UNFPA, UNICEF. NWZ

NWZ

NWZ

NEZ

NEZ

NEZ

CSZ

TOTAL

% of wrkforce

Doctors

Public 43

Private 42

(obstetrician)

Total 85

Public 32

Private 42

Total 74

Total 146

253

7

(4)

Qualified nurses Qualified midwives Auxiliaries & technicians

240

96

336

128

208

336

414

861

23

44

15

59

29

18

47

200

306

8

462

242

704

160

215

375

333

1412

38

TBAs TOTAL

153 942

395

153 1337

278 627

483

278 1110

467 1093

898 3730

24 100

Distribution of qualified health staff (midwives, doctors and nurses) varies widely with region, with clustering in urban areas as this example from 2003 in Puntland shows (see Table 3.4). Table 3.2

Health staff by region: Puntland

Source: Puntland Facts and Figures 2003, Ministry of Planning and Statistics, Puntland State of Somalia.

PUNTLAND (NEZ)

BARI

NUGAAL

SOOL

SANAAG

MUDUG

CAYN

TOTAL

MD**

28

7

7

0

19

1

62

Midwives

18

2

2

3

3

5

33

1

0

1

0

0

0

2

Nurses

25

42

35

16

17

5

140

CHW

72

120

19

20

60

4

295

TBAs

72

119

19

20

44

4

278

Post bas nurses

In CSZ, due to the unstable situation and lack of government capacity, there is little accurate updated information on HR-RH. Due to security constraints no mapping of the entire zone has been attempted recently. Information available is from NGOs who cover a geographical area in conjunction with UN-agencies. The following table is an example of HR-RH in a region, this for Lower Shabelle.

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Table 3.3

HR-RH in Lower Shabelle Region (per.comm. NGO/WHO)

Profession MD Surgeon Obstetrician/gynaecologist Qualified nurse Qualified midwife Auxiliary nurse/midwife TBAs TOTAL

3.2.1

No 5 2 0 26 18 160 320 531

% 1 0.4 0 5 3 30 60 99.4

Trends in skill mix, turnover and distribution

Surgeons/obstetricians: The exact numbers of qualified surgeons and obstetricians is not known. Obstetric surgery performed in Somalia is for the most part performed by surgeons, more rarely obstetricians/gynaecologists, and some nursemidwives have been trained and are performing certain procedures. Surgeons will rarely get involved in operative vaginal delivery, but have their role in CS and dealing with complications such as uterine rupture, obstetric hysterectomies and D&C. Some practicing gynaecologists are trained to perform CS and some not. Some nurse-midwives are trained (by NGOs) to perform D&C and CS. The quality of obstetric surgery has recently been evaluated and found to be non-standardized, and often performed with poor surgical skills51. MDs: Most doctors are graduates of Mogadishu University from before the 1990s and have more than 20 years of experience. Few doctors are found in rural areas. The population is aging and only recently have new doctors graduated. There is presently an existing two-year internship programme in Somaliland for new graduates which includes a six months rotation in the gyn/obs ward, where part of the training is to learn CS. Clinical officers: There are currently clinical officers being trained in one institution, but none are in clinical practice yet. Qualified midwives: Most midwives were educated before 1991, as nurses (three years) with additional training in obstetrics (one year) and have a reasonable level of skills. It has shown to be difficult to retain qualified midwives recruited from urban areas to rural areas. In Somaliland only around 20% of midwives practice in rural areas. Of the few newly educated midwives, many are recruited to NGOs and out of public service due to better financial revenues and lack of a comprehensive deployment plan from health authorities.

51

Personal communication, consultant WHO Somalia 2008.

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Concerning obstetric skills, some midwives are trained in minor obstetric surgery and assisted vaginal delivery. Community midwives: The first 21 community midwives are graduating in April/May 2009 after an 18-month course in Edna Adan MH, Somaliland. A plan for deployment, payment and supervision has not been developed. TBAs: There are no reliable overall estimates of percentages of TBAs who have been trained. Duration and quality of training has not been standardized, making comparisons difficult. Many of the trained TBAs occupy positions as auxiliary nurses.

3.3 3.3.1

Key human resource issues and concerns HR-RH: In-service training

Due to poor education and advanced age, a substantial proportion of staff are likely to be unsuitable for retraining. There is a need to look to future production of HR to assure qualified staff for RH. For existing staff, in-service training needs to be better coordinated than in the past. New possibilities are distance-learning courses offered by several agencies, as well as virtual networks such as Implementing Best Practices (IBP) (www.who.int). Assessing training needs as well as developing a prioritized plan for continuing medical education for different cadres can replace the sporadic efforts of today. 3.3.2

HR-RH: future production

Several public and private training institutions have started operations in recent years, offering medical and nursing programmes. A few hundred students are now enrolled in medical and nursing schools in Hargeisa, Boroma, Burao, Bosasso, Galcayo and Mogadishu. However, there is a shortage of competent teachers and training programmes still need to be standardized. Distance education courses supported by international universities/WHO are ongoing. An assessment of 14 health staff training institutions (WHO Somalia, 2008) showed new courses starting (especially in urban areas) of all zones, but mainly for nursing. Some post-basic courses in midwifery are taking place with first graduates expected over the next two years (Table 3.7). Many more nurses are being produced than nurse-midwives, responding to demand for short-term education rather than demands of the health sector. Doctors are currently educated in Somaliland and CSZ (Table 3.8). Presently no qualifying specialist-training in obstetrics, gynaecology or surgery occurs within Somalia.

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Table 3.4 Ongoing and planned training of midwives and community midwives Source: WHO 2008 Zone NWZ

Facility

Cadre

Institute of Health Sciences, Hargeisa Edna Aden Maternity Hospital, Hargeisa Edna Aden Maternity Hospital, Hargeisa

NEZ CSZ

College of Health Sciences, Nursing School, Bossaso Hayat Institute of Health Sciences, Mogadishu

Table 3.5

Graduation

Post-basicMidwifery (1y) Post-basic Midwifery (1y) Community midwife (1.5y) Post-basic Midwifery (1y) Post-basic Midwifery (1y)

Education of medical doctors

Zone

Location

Facility

NWZ

Boroma Hargeisa

Amoud University University of Hargeisa

NEZ

Bossaso Galcayo

CSZ

Mogadishu

Bosasso Faculty of Medicine Galcayo Faculty of Health Sciences Benadir Medical University

Planned for 15 graduates 2009 18 graduated in 2007, none in 2008 First 20 to be graduated 2009 First 30 to be graduated in 2009 (?) UNFPA supporting? Planned first 20 to graduated in 2009

Source: WHO 2008 Last/planned graduation 10 graduates in 2008 25 graduates planned for 2010 40 students 1.trimester 2009 Graduation planned for 2012 21 graduates planned for 2009

For the next two years (2009+2010) 65 post-basic midwives and 20 community midwives52 are planned to be graduated. It is likely to be producing enough nurses for enrolment into post-basic midwifery courses. 214 nurses are expected to graduate in 2008 and 470 are enrolled to graduate in 2010 (ibid). Dropout rates in the majority of institutions during the assessment were found to be more than 50% over three years. A major obstacle appears to be tuition fees - in general, the cheaper the fee the less dropouts. The quality of tuition was not directly assessed, but findings suggest that there is less monitoring of quality and usefulness of training as raw numbers take precedence. As more institutions are opened, student intake becomes more localized, most being drawn from the immediate urban centre.

52 Costs per trained community midwife (18 months) including stipend, accommodation and course: US$ 3,500-4,000 per midwife (personal communication, Edna Adan Maternity Hospital).

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3.4

HR management

Governmental health staff are normally recognized as civil servants. Lack of certification and few standard job descriptions are prevalent. Organograms for the different government facilities rarely correspond with actual staff present, as a large number of staff remain inactive but are still registered. The private sector operates without any regulation and salaries are governed by market forces. 3.4.1

Payment/incentives

Somaliland has a proposed civil service salary system in place, but cannot implement it due to restrictions in the budgetary resources and inadequate professionalization of the civil service (Davis, 2009). In general, in the public sector government staff is inadequately paid considering the cost of living and there are often breaks or delays in payments. In Puntland, governmental health staff has not been paid for most of 2008 due to a shortage of governmental funds. Gaps between private market salaries and current public wages are substantial. In a public MCH, a nurse typically receives US$ 20-50/month, whilst in the private sector the salary will typically be US$ 150-250/month (ibid). Workers in the public sector have access to extra income through DSA paid for workshops/trainings, private practice, sale of pharmaceuticals, etc. Most supporting agencies pay incentives or top-up salaries to workers in facilities. Incentive systems are very different in CSZ and in NWZ/NEZ, reflecting the relative peace and order in the different zones as poor security tends to push salaries up for scarce staff. 3.4.2

Regulation staff salaries

Proposals for the standardization of salaries and incentives have been made for Somaliland, but have yet to be implemented (ibid). The standardization of salaries, working hours and job descriptions and responsibilities will be a crucial step in assuring functioning facilities in the public sector. 3.4.3

Conclusions

The present health staff pool is small, aged and under-trained, with limited potential for retraining. Market forces governing present education of health staff will not adequately fill the gap in HR production for RH (esp. post-basic midwifery and professionals with skills in obstetric surgery). Major scaling-up of pre-service training for qualified and community midwives is a clear priority. The overwhelming share of urban recruited students must be counteracted by active rural recruitment. Subsidized courses linked to commitment of deployment within the public sector for two to three years with acceptable salary might assist in retaining staff in underserved areas. An increasing number of newly graduated MDs are available and eligible for inservice training in emergency obstetric surgery and care.

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4.

Information

4.1

Health information systems

Despite intense work on strengthening the health information system, data collection and analysis still remains fragmented with the Ministries of Health, different UN agencies, vertical programs and NGOs using their own formats to collect data. Overall, facility-based reporting is of low quality and limited coverage and there is weak capacity for information management at all levels. Catchment populations of health facilities are not clearly defined, making it difficult to estimate and monitor coverage indicators. HMIS software developed jointly by WHO and UNICEF is not widely used. Health information is not easily accessible to managers. 4.1.1

HMIS reproductive health

MCH facilities provide partly unreliable monthly summaries of primary healthcare activities. Hospitals data are also incomplete and unreliable. No data are collected from the private sector. In Puntland and the Central Southern Zone, no regional offices or central HMIS units are in place. UNICEF-designed HMIS forms are sent monthly from the MCHs to the regional UNICEF-office, then compiled and sent to the HMIS officer in Nairobi. The Somaliland MoHL uses an HMIS developed a few years ago. Formats are slightly different from UNICEF ones. An HMIS officer is present in each of the six regions of Somaliland, receiving reports from MCH but not from hospitals or HPs. Health facilities receiving support from MSF, ICRS and IFRC have separate reporting systems. Presently, GFATM is funding UNICEF piloting activities in Somaliland: two regional HMIS officers (Hargeisa and Berbera) and the head of HMIS unit are supported, supervision rounds to MCH and hospitals were carried out, and dissemination and feedback meetings were conducted. 4.1.2

Conclusion

HMIS systems are not standardized across programmes and implementing agencies, leading to a fragmented system. Redesign and revision of recording and reporting tools are underway under the leadership of UNICEF, to be piloted in hospitals in 2009. Core RH-indicators to be included in the final version, remain to be decided at this point.

78

5.

Finances

Table 5.1

Indicators Indicator

US$

Year

Source

Total per capita health sector aid financing

7.34

2006

Capobianco/World Bank 2007

Total per capita health sector financing including private funds and out-of-pocket expenditure

1220

2006

Average yearly expenditure on reproductive health (women 15-49 y)

1.40

2006

5.1

Capobianco/World Bank 2007 Capobianco/World Bank 2007

Healthcare finance and expenditure

Total per capita health sector aid financing was US$ 7 in 2006. If private funds including out of pocket expenditures are included, the estimate is US$ 12-20/capita (see table above). 5.1.1

Governmental spending on health

The Somaliland MoHL budget (2007) was US$ 960,000, two-thirds of which (US$ 672,000) were wages. External aid remains critical for implementation of ambulatory activities. Support provided by the international community to the health sector in Somaliland was US$ 3.7 million in 2004. The main donor was UNICEF. The Puntland MoH has inadequate funds available and external aid is the major source of health financing. The authorities of CSZ have little to no budget allocation for the health system, therefore external aid is the major health finance source. WHO & UNFPA support health training and some hospitals, while UNICEF provides basic drugs and equipments to MCHs. Many local & international NGOs support additional health facilities. 5.1.2

Donor spending on health

In Somalia, aid to the health sector is characterized by three main financier groups: Bilateral, multilateral and other donors providing direct and indirect funding to agencies and institutions working in Somalia Private financiers Diaspora remittances Health received about 10% of the US$ 390 million spent by the main donors in 2006, and in 2008 the Consolidated Appeal Process (CAP) budgeted US$ 55 million for the health cluster out of a total budget of US$ 452 million. Top donors to the CAP are the USA, the EC and the UK.

79

Figure 5.1

Percentage Contributions by Programs (2000-2006)

Source: Capobianco/World Bank 2006

During the period 2000-2006, health sector financing in Somalia progressively shifted from horizontal to vertical programs. Although spending on health increased threefold in seven years from US$ 23 million to $62 million in 2006, this was mainly due to the emergence of GTFAM as the main donor to health (Capobianco & Naidu, 2007). In 2006, 22% of was spent for malaria, HIV and TB and the polio eradication programme alone absorbed 20% of all donor funding for health between 2000-2006 (ibid). Concerning private financiers and diaspora remittances used for health expenditures, there is limited knowledge about proportions allocated for health, and reproductive health in particular. 5.1.3 Financing for Reproductive Health Reproductive health financing has been neglected for many years (see Figure 5.1). The current trend of vertical programs does not favour maternal health programs, pointing to the need for a health system approach. During the period 2000-2006 the average yearly expenditure on reproductive health per woman of child bearing age was US$ 0.50. It was only in 2006 that this amount increased to US$ 1.40 (see Figure 5.2).

80

Figure 5.2

Health Expenditures: Reproductive Health (2000-2006)

Source: Capobianco/World Bank 2006

Considering the poor reproductive health indicators for Somalia, there is a definite funding gap. Strategic prioritization of RH programs is a core future recommendation from The World Bank (ibid). Major donors to reproductive health (excluding HIV/AIDS) during the last two years (2007-2008) have been the EU, USA, Italian Cooperation, the Belgian government, SIDA, DFID and the New Zealand government. Most funds are emergency/humanitarian funds.

5.2

Payment of RH services

5.2.1 Out-of-pocket payments, cost-sharing and user fees Although introducing cost-sharing policies tends to limit access to health services if not accompanied by other measures, a cost-sharing mechanism is the main cost-recovery model, both in public and privately run facilities. Although exemption schemes exist in some places, the majority of reproductive health services are not free. Even where services are provided for free, drugs and equipment are not and even where a national costsharing framework is in place, e.g. in Somaliland, at facility level there seems to be little coherent implementation in terms of fee levels, criteria for exemption and use of collected fees. International NGOs conduct their own financial policies without coordination. Gaps in health care financing are met using funds from private remittances from the diaspora (Capobianco E, Naidu , 2007), religious organization or loans from extended family or clans. Private health care spending has been estimated at between 55-80% of all health financing53.

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5.3

Future financing of reproductive health services

The goal should be to ensure adequate, sustainable funds are available and allocated for accessible, affordable, efficient and equitable RH health care provision and consumption. In principle, there are five alternative methods of financing healthcare: 1.

Direct payment by users to providers (out-of-pocket payments).

2.

Payment by government or others to providers on behalf of users.

3.

Payment by compulsory social insurance set up by the government.

4.

Private health insurance.

5.

Community insurance.

In Somalia, without a central government or any high degree of organization capacity in the private sector, the options are limited to above alternatives 1, 2 and 5. The question of sustainability is also tricky in the Somali context where future finances are heavily dependent on donor funding. 5.3.1 Direct payment by users to providers (out-of-pocket payment) This is in reality the existing model in private and public facilities today, as government support to health care is very limited. In this model the question is how to best protect people from financial risk and disastrous expenditures, as well as secure performance and optimal spending of scarce resources. Financial exemption schemes for certain groups are an attempt to cushion the poor and vulnerable, but have in many places proved costly, inefficient and with low accountability. 5.3.2 Payment by government or other to providers on behalf of users a) Input-payment: e.g. payment of incentive to staff. Typical financial model used by many NGOs. Leaves little control of performance and does not encourage increased outputs. b) Process-payment: e.g. per diem for training. Used as incentive, but tends to become perverted and encourages absence from regular service, and is not linked to performance or output. c) Output-based payment: individual or facility performance funding. A fee for service is established for services and paid by a purchaser or other than the individual user. The output-based model has been tested in Rwanda (Meessen et al, 2006). At HC level, a shift from input-based fixed individual incentives to facility

82

performance funding was conducted. Performance was defined in a basic way through a set of key activities with a potentially high impact on the SRSXODWLRQ¶VKHDOWKVWDWXV An example of key activities was institutional deliveries, antenatal visits, family planning consultations and child immunization. The financial assets were used by the facility to pay salaries and supplies. 5.3.3 Performance-based financing in context Organizational capacity is low in Somalia and any performance-based financing or purchasing of services must be simple and easy to monitor. A simple output-based payment is the use of prepaid vouchers for selected services. The benefits are that vouchers require little organizational capacity; a drawback can be higher marginal costs. The purchaser would for e.g. buy fixed or flexible numbers of services, such as facility-based delivery, assisted vaginal delivery or emergency CS from an institution. Nominal vouchers for free services could be issued at one level for women being referred to a higher level. Concerning referrals, there must be rewards for referral as well, e.g. payment per referred woman. As with any purchasing system there is a potential for perverse developments and a simple monitoring and evaluation system must be set up. 5.3.4 Special considerations for maternal health services It is important to emphasize that maternal health services such as antenatal care have a strong element of preventive actions and should have as low a threshold as possible for the user. As previously shown, around a quarter of women across the zones report that affordability of ANC services is an issue determining access. Secondly, user fees that exclude poor and vulnerable groups will in addition dramatically lower program efficacy, as morbidity is not equally distributed across socioeconomic categories (exclusion of high risk). Thirdly, most referral EmOC facilities are underutilized today. A benefit of performance payment is that the facility can plan for a higher activity level and can keep support staff for longer hours and pay them better. This can make the facilities financially vital and will have a positive feedback on services. This is true for both CEmOC and BEmOC centres. 5.3.5 Who will purchase services? For the intermediate period, national or international donors will be the main purchaser of services. With the development of a national strategy funding can be better aligned according to identified key priorities to exploit synergistic effects.

83

5.3.6 Community-based insurance schemes/community pooled funds Community-based insurance is a system in which the local community has pooled available funds gathered from the community that can contribute towards individual costs. Although one can find certain community initiatives today in Somalia, the technical and organizational capacity to develop such initiatives further has been limited. How to assure that resources will be prioritized for maternal health is a major challenge. If arrangements do not include prepayment to a facility, such schemes will have little impact on the facilities providing services. Community involvement or consultation at the time of decision (e.g. for a referral) is likely to cause delay. Community funds have been shown to be successful as emergency loans for transport for obstetric emergencies, such as a revolving emergency fuel fund set up in Nigeria (Shehu et al, 1997). Community-based financing at scale needs more investigation in context. 5.3.7 Conclusion Shifting from an input-based to an output-based facility financing, taking into consideration the particular aspects of maternal health services, will help facilities work and ensure performance in areas of importance to maternal and neonatal survival. Community-based finance schemes need to be evaluated for effect and usefulness for maternal and neonatal health.

84

6.

Medical products and technologies

6.1

RH commodity supply and distribution

The supply of RH commodities to health facilities is based on delivery of prepacked standardized kits. UNFPA and UNICEF are the major suppliers through international and local NGOs. UNICEF supports a large number of health centres/MCHs and health posts. UNFPA mainly delivers to the zonal MoH, who then distribute further to hospitals and MCHs. Due to difficult access and lack of staff training, kit-based distribution has been considered the only viable and realistic option for the immediate future distribution of commodities. Frequents stock-outs of main drugs and vaccines for antenatal care have been documented and are thought to hamper attendance, especially at MCH-level. There is thus a need for immediate revision of kit content. Concerning specific items, oxytocine is generally not supplied to MCHs by UNFPA; this is a major gap if MCHs are to function as BEmOC centres or even as normal delivery points. UNFPA is the only agency allowed the purchase of contraceptives; if a child spacing programme is to succeed, these need to be delivered at the MCH/health centre level along the same logistic lines as the UNICEF kits. At the moment there is no collaboration between UNICEF and UNFPA on logistics and there is certainly potential for alignment and harmonization of kits, as well as storage, transport and distribution mechanisms. 6.1.1 Conclusion There is a potential for better alignment between agencies who deliver kits to health facilities, both concerning urgent revision of kit content and synchronizing logistics. For individual clean delivery kits (UNFPA Kit 2), these are presently ordered from Europe (Copenhagen). Items are available locally and if this activity is to proceed, shifting to local procurement, production and sale of kits would be a sustainable solution.

85

7.

Governance

7.1

Governance in RH

In the absence of a central government in Somalia, the international donor community and health sector stakeholders developed a mechanism to guide and coordinate external assistance to the country. This interim arrangement, known as the Coordination of International Support for Somalia (CISS), set up five sector coordination platforms (one of which is for health), with a series of working groups under each platform. The Health Sector Committee was established to develop a joint common vision and provide guidelines to increase efficiency and effectiveness of investments in the health sector in Somalia. As part of this technical coordination, a RH working group was previously operational but ceased to operate through lack of participation. The re-launch has been discussed but has yet to become operational. There is thus little communication and/or cooperation between the main actors in reproductive health, including between UNFPA, WHO and UNICEF. The organograms of the Ministries of Health in the different zones are presented in the Annexes. There is theoretically a reproductive health unit or focal point/person in each, but the function is highly variable. Working groups at zonal levels still remain to be created. 7.1.1 NWZ Despite increased capacity in the MoHL and relatively good working conditions in terms of security during the last few years, a fragmented approach to reproductive health has remained. In Somaliland there is a draft National Health Policy in place from 1997 (Ministry of Health and Labour Somaliland, 1999), but this has yet to be endorsed by lawmakers. In this, a basic package for maternal services at primary health care level is described and includes services such as antenatal care, delivery care and postnatal care, including provision of micronutrient supplements and prevention of malaria. For care at referral level the policy is less clear. There is currently no reproductive health policy. 7.1.2 NEZ A National Health Policy is in place but gives little direction for reproductive health programs. Presently no reproductive health policy is established. 7.1.3 CSZ There is no functional public health authority in place, and no policies. 7.1.4 Conclusion National reproductive health policies and strategies need to be developed for each zone. Governance structures and consortia must be established to ensure national programme ownership. Interagency collaboration, coordination and convergence of RH services must be improved at all levels.

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8.

Discussion

8.1

Addressing maternal and neonatal survival

To address the documented unacceptably high burden of maternal and neonatal deaths and disability in Somalia today, considerations needs to focus on which intervention will be effective and feasible in this complex environment. The many contextual restraints also make it necessary to define clear priorities from an early stage. Maternal and neonatal survival are key priorities in such a context. From a public health perspective, the lack of a comprehensive public family planning program with good coverage at the health centre level is one of the most obvious gaps in reproductive health in Somalia. Reducing the very high fertility rates in an environment of documented unmet needs of pregnancy prevention, will reduce the number of pregnancy complications and avert a considerable number of maternal and neonatal deaths. Few other single interventions have shown similar effects in reduction of maternal deaths in other settings. Another major gap is the lack of universal skilled care at childbirth. Although established as the universal gold standard, concerns have been raised in similar contexts as to the feasibility in the medium term considering financial and human resource constraints54. There is a need to perform a reality check as to how this may be achieved in the Somali context. For the intermediate future, despite any policy, home births will continue. Looking at the low population density in rural areas, the current lack of a functional health system in Somalia as well as a cultural preference for home births, universal coverage of facility-based deliveries will remain an organizational and financial utopia in the short term. To ensure that some sustained facilities do function and expand services to achieve geographical coverage, there must be a starting point. To get there, issues that need to be addressed are many. The underutilized resource of health staff for public facilities must be taken advantage of, keeping workers in the sector by paying realistic salaries according to an accepted scale and making the 42-hour work week a reality. Realistic opening hours needs to be expanded. Mechanisms encouraging facilities to perform better, such as output-based procurement of services by donors, can be combined with individual staff incentives according to performance. Incentives to improve facility utilization such as delivering at a health facility, have already been piloted by some NGOs and can be important in advertising and promoting services. This might especially be important in the initial phase after 54 Studies from similar contexts such as Nepal have shown that institutional deliveries impose a far higher financial burden on the health system and the individual than skilled attendance at home births (Borghi et al. 2006). Implementation of universal facility delivery in the short term was considered highly unrealistic in Nepal given insufficient human and infrastructural capacity and lack of community acceptance given the preference for home deliveries.

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upgrading of services and of less importance when the population is aware of affordable quality services. Improved supply chain by revised kits and shared logistics between implementing partners are important to address missed opportunities and reduce costs. Another major gap is the lack of any scale of reproductive health education for core staff. The urgent need for qualified midwives and community midwives in all zones must be taken into consideration and a dramatic scaling up of training capacity must be a priority. The first study showing that traditional birth attendants in Somalia cannot effectively save the lives of mothers is more than 10 years old. It is time to act now to make sure another decade does not pass before effective interventions and rational use of resources are assured.

8.2

Bridging the gaps

Whilst a dramatic scaling up of pre-service training is essential to kick start the process, there are still issues concerning existing services that can be improved. There is an urgent need to lower access barriers to utilization of facilities. Financial barriers such as user fees must be addressed and, for core preventive services, these must be free of charge. Other barriers are poor service quality and inadequate service hours. There is a need to work out realistic mechanisms for referral. Intrapartum referral is extremely difficult to ensure with the geographical, logistical and financial obstacles present in Somalia. It is not realistic to look at systems where health care comes to the patient, i.e. so-calOHG³IO\LQJVHUYLFHV´The only realistic option is to look at a system where rural or nomadic patients come to the services. For delivery purposes this means setting up maternity waiting homes which, in conjunction with upgrading of existing facilities, can compensate for the vast differences in access to services for rural and urban populations. It will not necessarily have an impact if conducted as a single intervention; maternity shelters are but one link in the long chain leading to successful pregnancy outcomes for mother and baby (see Annex L).

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8.3

Community mobilization for reproductive health services55

It has been shown that raising SXEOLFDZDUHQHVVRIZRPHQ¶VVSHFLDOQHHGV during pregnancy and birth is essential for the impact of any program action in Somalia, due to the current low awareness of reproductive health risks even among health workers. The Lady Health Worker Programme in Pakistan (Oxford Policy Management, 2002) has shown good impacts of the cadre on the uptake of family planning services, and similar female community health workers conducting home visits in Somalia could be of benefit although significant organizational restraints exist due to the low population density in many areas. Due to lack of governmental organization, especially in the CSZ, involvement of key community actors (sheiks, clan and religious leaders, additional FRPPXQLW\OHDGHUVDQGZRPHQ¶VQHWZRUNV must happen at an early stage to ensure understanding and involvement. With regard to family planning, involving men, and addressing misconceptions about modern child spacing methods are crucial. Radio is the major source of health information among Somalis, as well as being the most preferred and trusted source of information. Simple IOE messages delivered through plays and talk shows on radio have been shown to be recognized. Once affordable, quality delivery, EmOC and child spacing services are up and running, community mobilization should be directed at opinion-leaders and decision-makers such as religious leaders, PHQ¶VJURXSVZRPHQ¶V groups etc. to assure increased utilization and trust of services.

55 Many safe motherhood analysts such as policy-makers and academics would consider community mobilization a peripheral component of a package to reduce maternal mortality which is far more dependent on specific facility-based interventions than is e.g. child survival. Evidence from countries such as Pakistan and Nepal has shown that community mobilization has improved care practices, increased use of health services, promoted timely referral and reduced social disadvantages (Zulfiqar et al, 2005).

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9.

Summary of conclusions and recommendations

9.1

Essential and Emergency Obstetric Care Skilled attendance at birth is the ultimate goal. Dramatically increase the number of midwives for the public sector by scaling up post-basic midwifery and community midwifery preservice training in all three zones, linked to mechanisms for deployment, motivation and retention. Increase number of professionals eligible for obstetric surgery by establishing three to six months in-service training in Emergency Obstetric Care for newly graduating doctors. Comprehensive refresher EmOC in-service training for all doctors and midwives. Increase access to EmOC by upgrading existing MCHs to health centres that can provide Basic Emergency Obstetric Care within referral distance of a facility offering Comprehensive Emergency Obstetric Services with the appropriate referral mechanisms. Initiate maternity waiting shelters to improve access for rural and nomadic population to Emergency Obstetric Care. Ensure affordable services with free referral vouchers for major obstetric interventions and facility-based births. Intermediate-term measures to assure skilled attendance at home births such as scaling up training of community midwives. Explore innovative practices such as incentivized referral and new roles for unskilled staff, such as a role in newborn care and recruitment into other cadres such as the CHW. Classic traditional birth attendant training in safe delivery to be phased out. Due to the gap in skilled care at delivery to be expected during the intermediate period, strategies to bridge gaps must remain whilst waiting for human resource outputs. In areas where no skilled care is available, the role of TBAs will be transformed to one of prepartum referral to facility-based care, a role in newborn care and possibly a role in piloting communitybased distribution of new RH technologies such as Misoprostol to prevent postpartum haemorrhage. Exploration of innovative practices such as incentivized referral and recruitment into other cadres, such as CHW.

9.2

Antenatal, postpartum and neonatal care Address underutilized public sector health staff by paying realistic salaries according to accepted scales, to be able to expand opening hours at health centres and improve performance.

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Explore performance-based financing and incentives. Improve supply chain with revised kits and shared logistics between partners. Scale up in-service training capacity with a focus on major gaps. Adapt and update protocols and guidelines in place. Improve quality and comprehensiveness of antenatal and neonatal care by addressing missed opportunities. Explore innovative practices such as incentivized referral and new roles for unskilled staff, among them TBAs, such as a role in newborn care and recruitment into other cadres such as the CHW. Integrate prevention of STI and HIV-AIDS at health centre level. Ensure increased community demand for services by reinventing the role of community health worker to one of trained, paid, and extended arm of the health centre.

9.3

Birth spacing/limiting and prevention of pregnancy Universal affordable access to a choice of a reasonable mix of contraceptive methods at each level of health facility. Address training needs of health staff. Introduce national guidelines, as well as protocols for facilities. Early involvement of men and key community actors, including religious leaders for programmatic sanction. Expand demand by extensive behaviour change communication through community health workers and health facilities, emphasizing the positive health benefits of birth spacing.

9.4. Obstetric fistula, post-abortion care and sexual- and gender-based violence, including FGM Make prevention a priority by increasing access to quality Emergency Obstetric Care services. Prepartum referral to waiting shelter for primiparas in rural and nomadic areas. Adequate family planning program to delay first pregnancy beyond early adolescence. Increase access to and quality of health services and commodities for comprehensive management of post-abortion care, fistula, sexual- and gender-based violence, including complications of female genital mutilation. Increase awareness of harmful effects of FGM among decision-makers in the community.

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9.5

Human resources, finances and governance Scaling up graduation of quality post-basic and community midwives in all three zones. Recruit new doctors to in-service emergency obstetric care training. Ensure more equitable coverage of rural and underserved areas, by recruitment from such areas linked to deployment and commitment to placement for a defined time period with adequate reimbursement and career opportunities. Innovative and sustainable RH financing mechanisms where necessary. Explore performance-based financing to increase output and efficiency of existing facilities and health staff. Establish reproductive health national policies and develop strategies for each zone. Establish governance structures and consortia to ensure national programme ownership. Improved interagency collaboration, coordination and convergence of RH services at all levels.

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REFERENCES Ahmed HJ et al. (1991). Syphilis and human immunodeficiency virus seroconversion during a 6-month follow-up of female prostitutes in Mogadishu, Somalia. Int J STD AIDS 2(2):119-23. Abdel-mohnsen A. (1998). Reducing risky pregnancies in Somalia. Plan Parent Chall. 1,23. Beesley M. (2008). A Recommended Human Resource Development Plan. WHO Somalia. Bile K et al. (1991). Late seroconversion to Hepatitis B in a Somali village indicates the important role of venereal transmission. J Trop Med Hyg. 94(6):367-73. Borghi J et al. (2006). Financial implications of skilled attendance at delivery in Nepal. Tropical Medicine and International Health 11 (2), 228-37. Capobianco E & Naidu V. (2007). A Review of Health Sector Aid financing to Somalia 2000-2006. The World Bank. Carroli G et al. (2001). WHO systematic review of randomized controlled trials of routine antenatal care. The Lancet 357,: 1565-70. Conde-Agudelo A. (2007). Effects of birth spacing on maternal health: a systematic review. American Journal of Obstetrics and Gynecology 297-308. Davis A. (2009). Intermediate Standardized Salary Support/Incentive: Payment Scales for Civil Servants and Health Workers. UNICEF-Somalia, Nairobi. FSAU. (2007). Somali Knowledge, Attitude and Practices Study (KAP) ± Infant and young child feeding and health seeking practices. Goodburn E. (2000). Training traditional birth attendants in clean delivery does not prevent postpartum infection. Health Policy and Planning 15(4), 394-99. Oxford University Press. Gordon H, Comerasamy H & Morris NH. (2007). Female genital mutilation: Experience in a West-London clinic. Journal of Obstetrics and Gynaecology 27(4): 416-9. Health Unlimited Somalia. (2008). KAP Baseline Survey Reproductive Health and EmOC Intervention in Maroodi Jeex District, Somaliland. Jarabi BO. (2007). Review of various population estimated for Somaliland, Puntland and South-Central Somalia.´81'3. Lawn J, Shibuya K & Stein C. (2005). No cry at birth: global estimates of intrapartum stillbirths and intrapartum-related neonatal deaths. Bull World Health Organ. 83(6):409-17. Maine D. (2007). Shortcuts and detours to maternal health. The Lancet 13;370(9595):1380-2 McClure et al. (2007). Maternal mortality, stillbirth and measures of obstetric care in developing and developed countries. International Journal of Gynecology and Obstetrics 96:139-46. Meessen B, et al. (2006). Reviewing institutions of rural health centres: the Performance Initiative in Butar, Rwanda. Tropical Medicine and International Health *.

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Ministry of Health and Labour Somaliland. (1999) Somaliland National Health Policy 1999. Ministry of Health and Labour Somaliland. (2006). Annual Health Report 2006. Oxford Policy Management. (2002). Lady Health Worker Programme: External Evaluation of the National Programme for Family Planning and Primary Health Care - Final Report. Ronsmans C. (1998). Short birth intervals don't kill women: evidence from Matlab, Bangladesh. Stud Fam Plann. 29, 282-90. Rutstein S. (2005). Effects of preceding birth intervals on neonatal, infant and underfive years mortality and nutritional status in developing countries: evidence from the demographic and health surveys, Int J Gynaecol Obstet 89 Suppl 1:S724. Save the Children UK. (2008). Health Baseline Survey for Togdheer Region, Somaliland. Shehu D, Ikeh AT & Kuna MJ. (1997). Mobilizing transport for obstetric emergencies in northwestern Nigeria. International Journal of Gynecology and Obstetrics 59 (2) 173-80. Sibley LM et al. (2007). Traditional birth attendant training for improving health behaviours and pregnancy outcomes. Cochrane Database Syst Rev. 18;(3):CD00546. Taghreed A. et al. (2005). Cost effectiveness analysis of strategies for maternal and neonatal health in developing countries. BMJ 331:1107. Tew M. (1998). Safer Childbirth? A Critical History of Maternity Care. Chapman & Hall. Thaddeus S & Maine D. (1991). Too far to walk: maternal mortality in context. Newsl Womens Glob Netw Reprod Rights 36: 22-24. UNDP. (2006). Somalia Settlement Survey 2006. UNFPA Somalia. (2008). An assessment survey of the youth status in urban towns of Garowe, Quardo and Bosasso in Puntland State of Somalia. UNFPA/The World Bank. (2005). Female Genital Mutilation/Cutting in Somalia. UNFPA Geneva. (2005). Needs assessment of Obstetric Fistula in Selected Zones in Somalia. UNFPA/UNAIDS/WHO Somalia. (2008). Joint mission to Sanag, Togdheer and Saahil regions to assess health facilities and human capacity to provide services. UNICEF Somalia. (1998). Traditional Birth Attendants in Somalia. UNICEF Somalia. (2004). Knowledge, Attitudes, Behaviour and Practices (KABP) on HIV/AIDS and Sexually Transmitted Infections among Somalis. UNICEF Somalia. (2006). Multiple Indicator Cluster Survey (MICS). UNICEF Somalia .(2008). National Primary Management Information Report Somalia and Somaliland 2007. UNICEF/UNFPA Somalia. (2006). Needs Assessment of Emergency Obstetric Care in Somaliland and Puntland.

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WHO. (2006a). Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries. The Lancet 367: 9516: 1066. WHO. (2006b). WHO Analysis of Causes of Maternal Deaths. The Lancet 367:9516: 1066. WHO. 2007. Neonatal and Perinatal Mortality. Geneva, MPS/HQ. WHO Somalia. (2008). A Survey of Somali Pre-Service Health Training Institutions. WHO/ICM/FIGO (2004). Making Pregnancy Safer: the critical role of the skilled attendant. Geneva. Zulfiqar B, Darmstadt G, Hasan B & Haws R. (2005). Community-based interventions for improving perinatal and neonatal health outcomes in developing countries: a review of the evidence. Pediatrics 115, 519-617.

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ANNEX A: WHO shortlist of Reproductive Health Indicators for Global Monitoring Source: WHO 2000, 2001. 1. Total Fertility Rate (TFR) Total number of children a woman would have by the end of her reproductive period if she experienced currently prevailing age-specific fertility rates throughout her childbearing life. 2. Contraceptive Prevalence Rate (CPR)56 Percent of women of reproductive age (15-49) who are using (or whose partner is using) a contraceptive method at a particular point in time. 3. Maternal Mortality Ratio (MMR) Annual number of maternal deaths per 100,000 live births. 4. Antenatal Care Coverage Percent of women attended at least once during pregnancy by skilled health personnel (excluding trained or untrained traditional birth attendants) for reasons relating to pregnancy. 5. Percent of births attended by skilled health personnel Percent of births attended by skilled health personnel (excluding trained or untrained traditional birth attendants). 6. Availability of Basic Essential Obstetric Care Number of facilities with functioning basic essential obstetric care per 500,000 population. 7. Availability of Comprehensive Essential Obstetric Care Number of facilities with functioning comprehensive essential obstetric care per 500,000 population. 8. Perinatal Mortality Rate (PMR) Number of perinatal deaths per 1,000 total births. 9. Low birth weight prevalence Percent of live births that weigh less than 2,500g. 10. Positive syphilis serology prevalence in pregnant women Percent of pregnant women (15-24) attending antenatal clinics whose blood has been screened for syphilis, with positive serology for syphilis. 11. Prevalence of anaemia in women Percent of women of reproductive age (15-49) screened for haemoglobin levels with levels 110g/l for pregnant women, and 120g/l for non-pregnant women.

56

The expert group working with WHO on this set of indicators recommends basing the calculation of contraceptive prevalence on all women of reproductive age, in contrast to the convention used by the DHS and RHS to report it for married women only (or married and unmarried women separately)

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12. Percent of obstetric and gynaecological admissions owing to abortion Percent of all cases admitted to service delivery points providing in-patient obstetric and gynaecological services, which are due to abortion (spontaneous and induced, but excluding planned termination of pregnancy). 13. Reported prevalence of women with FGC Percent of women interviewed in a community survey reporting having undergone FGC. 14. Prevalence of infertility in women Percent of women of reproductive age (15-49) at risk of pregnancy (not pregnant, sexually active, non-contracepting, and non-lactating) who report trying for a pregnancy for two years or more. 15. Reported incidence of urethritis in men Percent of men aged (15-49) interviewed in a community survey reporting episodes of urethritis in the last 12 months. 16. HIV prevalence among pregnant women Percent of pregnant women (15-24) attending antenatal clinics, whose blood has been screened for HIV and are sero-positive for HIV. 17. Knowledge of HIV-related prevention practices Percent of all respondents correctly identifying all three major ways of preventing sexual transmission of HIV and who reject three major misconceptions about HIV transmission or prevention.

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ANNEX B: Institutions and persons visited in Hargeisa, Feb 8th ± 11th 2009. 1. UNDSS Field Security Officer Hargeisa 2. Somaliland MOHL: Dr. Anwar Mohamed Eegh, Director General for Health 3. WHO Hargeisa: Ms.Asia, Focal Point Reproductive Health 4. Hargeisa Group Hospital / Dr. Yassin 5. Hargeisa Group Hospital: Community midwives + midwife tutor 6. Manhall Speciality Hospital/ Dr. Behi/ Dr.Asha/ Matron Fausia Isman 7. UNFPA Hargeisa / Program Assistant Salada 8. Fouzia Mohamed Ismail, Chief Executive Director, Somaliland Nursing and Midwifery Association (SLNMA) 9. Shinoor MCH, outskirts of Hargeisa (urban), IDP area/ Team leader Suhur 10.

Edna Adan Maternity Hospital /Ms. Edna Adan

11.

WHO Human Capacity Building HIV/AIDS/ Ms. Nawal Diriye

12.

THET/Clinical instructor Rosemary Munangatire

13. UNICEF Hargeisa/ Ms. Marian Yusuf Fahiye, Maternal Child Health Focal Point 14.

PSI Hargeisa/ Louise Norman

15.

Somaliland Medical Association

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ANNEX C: Basic and Comprehensive Obstetric Care Basic and Emergency Obstetric Care Emergency Obstetric Care is evaluated through categorizing facilities according to their capacity to perform signal, or core, functions. These apply when a delivery goes from being normal to being complicated. BEmOC can be performed by trained nurse-midwives at health centre level. Facilities that offer Comprehensive Emergency Obstetric Care (CEmOC) offer all the signal functions of BEmOC, but can also offer Caesarean sections and other obstetric/surgical interventions, as well as blood transfusions. This happens at referral level, most often at hospital level. For a facility to be able to perform Basic Emergency Obstetric Care (BEmOC), the following signal functions need to be in place:

Signal functions Basic Emergency Obstetric Care (BEmOC): * Parenteral antibiotics * Parenteral oxytocic drugs * Parenteral anticonvulsants * Manual removal of placenta * Removal of retained products * Assisted vaginal delivery

Signal functions Comprehensive Emergency Obstetric Care (CEmOC): All the above plus: * Surgery (e.g. caesarean delivery) * Blood transfusion

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ANNEX D: Monitoring and evaluation tools of obstetric and neonatal care: UN process indicators As maternal or neonatal mortality or morbidity are too-infrequent events to be used as a continuous monitoring tool for the functioning of EmOC services, UNICEF/WHO/UNFPA in 1997 developed process indicators that monitor changes in access to, utilization of and quality of EmOC services. These indicators will be used in this report to evaluate the status of obstetric care in Somalia today.

UN process indicators: Indicator 1: Coverage facilities vs. population: For every 500.000 population there should be at least: 1 CEmOC facility 4 BEmOC facility Indicator 2: Geographical distributions of EmOC facilities: EmOC facilities should be well-distributed to serve 500,000 people. Indicator 3: Proportion of all births in EmOC facilities: At least 15% of all births in the community should take place in facilities. Indicator 4: Met Need for EmOC services: At least all women estimated to have obstetric complications should be treated in EmOC facilities Indicator 5: Caesarean sections as a percentage of all births: Between 5-15%. Indicator 6: Case fatality rate: Proportion of women with obstetric complications admitted to a facility who die is < 1 %. Indicator 7: Neonatal care: Neonatal resuscitation.

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ANNEX E: ([FHUSWVIURP³7KH(VVHQWLDO3DFNDJHRI+HDOWK 6HUYLFHV´ Source: UNICEF Somalia, 2009.

Excerpt E1: The four service levels Primary Health Unit The primary health unit is staffed by at least one trained Community Health Worker (CHW) supported by an elected, representative Community Health Committee that participates in the response to the common causes of ill health affecting the community. The emphasis is on prevention of disease and promotion of health through nutrition education, health seeking behaviour, vaccination, mosquito nets and improvements in water and sanitation. The CHWs are not nurses, but they are trained to diagnose and treat a few common problems, such as malaria, diarrhoea and ARI particularly in children. They do not do maternal care such as deliveries or conduct antenatal clinics, but they do promote family planning and distribute pills and condoms. Immunisation clinics and therapeutic nutrition programmes are carried out as an outreach service by nurses from health centres assisted by CHWs, but CHWs also routinely screen under-fives and pregnant women for malnutrition with MUAC. CHWs are responsible for surveillance of epidemic disease and are obliged to record their activities at this first level of the HMIS. As employed personnel, CHWs must fulfil contractual obligations and meet performance targets. No fees are charged at PHUs. Health posts can be considered for inclusion as PHUs, but many very poorly functioning HPs will not be supported until they can fulfil PHU criteria and will not initially qualify for drugs, equipment and supervision. Community health workers carry out certain promotional, preventive and curative interventions from Core Programmes 1 to 6 as specified in the annexes. Once CHW training is established and CHWs are properly supervised, some regions may pilot Community Health Promoter training (see Annexes). CHPs would not be employed within the health system, and would be volunteers with a purely promotional and mobilising role within communities. Their point of contact would be the PHUs. Health Centre The health centre is the key unit of the essential package at which all core programmes are carried out. It is the first level at which obstetric services are provided including ANC and facility based delivery with qualified midwives. The minimum number of staff is a qualified midwife, qualified nurse, and a qualified auxiliary nurse and community midwife. As well as maternity beds there are a minimum of 6 beds for 24 hour observation of sick patients. A Primary Health Officer is a qualified nurse responsible for nutritional and EPI activities in the health centre as well outreach clinics at the PHUs. A Community Health Committee is involved in the management of the health centre with the health team, and they are involved in raising funds at community level. No user fees are charged at health centre level. Health centres have fridges to guarantee the cold chain. Core programmes 1 - 6 are all applied at the health centre in their entirety except for a few interventions (marked in italics) that only take place at referral health centre level. Additional programmes 7 to 10 are not operational at health centre level in the first two phases. Referral Health Centre

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Referral health centres and district hospitals carry out all Core Programmes 1 - 6 and add Additional Programmes 7 - 10 for treating people with mental illness and chronic disease, and dental and eye disease, via outreach visits by specialists from the regional level. They carry out comprehensive emergency obstetric and newborn care, with the capacity for carrying out caesarean sections and blood transfusion. The surgical facilities also allow tubal ligations to be carried out, as well as IUDs and implants to be fitted. They have at least eight bed maternity wards and an in-patient facility for at least 20 patients. The staff include at least two midwives and two qualified nurses and a health/clinical officer. They have a Primary Health Officer (nurse) for EPI and nutrition and a laboratory technician. Referral health centres have fridges and freezers, acting as EPI depots. Health centre committees ensure community support for the health facility, as well as leading community based responses to health challenges. They also are responsible to mobilise funds from the community, the local businesses, diaspora populations and other potential resources. The Regional Health Office is responsible for supervision of HCs and RHCs. There is potential in future phases for the RHCs to become district hospitals, but in these first two phases of EPHS development, the priority is on establishing quality health centres, RHCs and a few key referral hospitals from the existing health facilities and on strengthening supervisory capabilities at Regional Health Offices. Hospital The hospital ensures 24-hour quality inpatient referral health care with qualified nurses, midwives and doctors permanently in the hospital. Core and additional programmes are expanded in hospital departments, each often run by specialist medical and nursing practitioners, who may also conduct outreach clinics to RHCs. Management is the task of a hospital administrator (MBA level) overseen by the hospital director and the Regional Health Office. Health Boards are responsible for mobilising funds in the community, and from business enterprises, the diaspora and other sources. MOH and Municipal authorities also contribute to hospital fixed and variable costs. Regional EPI depots ensure regular vaccine supplies to the districts. A regional medical store is sited separate from the hospital, and eventually the EPI depot would be at the same location. Health systems support components Health systems support components are designed to maximise efficiency throughout the health care system, ensuring that sufficient resources are available for actual service delivery. Drug supply The drug supply system is changed from the distribution of drug kits to a consumption-based system that ensures appropriate oversight and monitoring of drug prescribing patterns. PHU, HC and RHC levels use a simple system of stock cards and drug order forms (found in the Annexes). Guidance and on-site training for ensuring adequate drug supply and for maintaining drug stocks (including buffer drug stocks) is provided through regional level supervision. At the hospital level, a more advanced stock control system, involving stock cards with a standardised software tool is required. Region-wide medical stores, based at regional health offices, also use a more advanced, software-enabled system. At the regional office, a pharmacy technician is in place to manage drug ordering and stock control for all public sector health facilities in the region. Drug supply distribution is

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outsourced to private sector contractors, who bid for distribution contracts on a competitive basis. Referral system The referral system consists of a referral letter, with space for comments by the referral clinician. Referring health providers will assist patients with arranging transport to the referral facility if necessary. Patients are encouraged to bring the updated referral letter back to the referring provider at their next visit. Referral criteria, and the protocols to be followed in the case of a referred patient, are required at each service level. The referral system will inevitably not work linearly in the first phase, so if a regional hospital is close to a health centre then referrals will as likely be there and not to a referral health centre. Transportation A transportation system is in place both for referrals throughout the health care system and for supervision. Transport via community-level resources (e.g. camel, donkey cart, vehicle if available, etc.) is the most appropriate means of patient transport from communities to PHUs, from PHUs to HCs, and from HCs to RHCs. At the regional hospital level and at the regional office, vehicles are used (and motorbike ambulances piloted), both for emergency transport where feasible, and for supervisory support to the lower level facilities throughout the region or district. Donors support orientation and training meetings for staff responsible for transport and encourage them to develop transport protocols based upon MoH transport policy. Donors also fund selected small capital and some recurrent expenses such as new donkey carts, repair and maintenance of carts, and fuel, maintenance and repair of regional office based vehicles.

Communications Mobile phones are the standard communication tool for all health facilities where there is a network, and are used for notification in the case of emergency or urgent referrals, as well as for systems support functions, e.g., informing medical stores units of unexpected stockouts of key drugs or medical supplies that require urgent replacement. Health facilities outside of mobile networks have HF radios to communicate to regions and referral health centres. To function HF radios need antennae, cable, and power sources (solar panels, batteries and cable if no electricity supply). Health equipment maintenance and repair Basic maintenance and repair of health equipment is the responsibility of the Ministries of Health and the implementing agents, possibly through sub-contracts with domestic or international firms. Cold chain technicians also service other equipment. Equipment across the health service is standardized as much as possible. Physical infrastructure maintenance and repair Health Committees have the responsibility for physical infrastructure maintenance and repair, with financing drawn from the local Community Health Fund. Community committees mobilize volunteers to paint or whitewash health facilities, and are responsible for minor repairs and upkeep. Major repairs and major renovation of existing facilities, are funded to the extent possible from the CHF, supplemented by resources from district authorities, donors and the MoH.

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Excerpt E2: Core and four additional programmes of the Essential Package of Health Services

Core programme 1 ± Maternal, reproductive and neonatal health Standardised interventions by sub-programme Sub-programme Promotion of maternal nutrition

Targeted supplementary feeding Promotion of neonatal nutrition Antenatal care

Interventions Promotion of appropriate nutrition for pregnant & lactating women, girls & adolescents; MUAC screening and referral Antenatal - Iron/folate supplements for 6 months & Vit A 10,000iu once; or combined multiple micronutrient supplements, 1 RNI per day Postnatal ± Iron/folate supplements for 3 months; Vit. A 200,000iu once during first 6 weeks for mothers or MMN - 1 RNI57 each day Context specific, in liaison with MOH, WFP, UNICEF and agencies for acutely malnourished pregnant and lactating women promotion of immediate and exclusive breast feeding referral health centres/ hospitals: nutritional care of premature babies and term babies without a mother promotion of facility based delivery assisted by skilled birth attendants CHPs and PHWs encourage bring women to go to health facilities to deliver Four focused antenatal visits including: ƒ At least two doses of tetanus toxoid vaccination (TT2+) ƒ Intermittent preventive treatment for malaria in pregnancy (IPTp) and insecticide treated bednets (ITN) in endemic areas ƒ Maternal nutrition counselling during pregnancy, including iron and folate supplements; MUAC screening and referral ƒ Treatment of disease, and mebendazole for worms ƒ Treatment of anaemia ƒ screening for pre-eclampsia with urine protein dipstick and BP and further ANC monitoring ƒ treatment of STIs Identification of high risk pregnancies and referral with register of at-risk pregnancies and referrals to maternity village (pilot programmes) Standardised management of pre-eclampsia, antepartum haemorrhage and other antenatal complications Prevention of mother-to-child transmission of HIV promotion of family planning for after delivery

Care during delivery

Care after birth

Family planning

57

Skilled in-facility attendance at birth with EmONC for all deliveries, including management of post-partum sepsis and haemorrhage, use of partogrammes and active management of third stage of labour; &RPSDQLRQRIWKHZRPDQ¶VFKRLFHDWELUWKDQGIOH[LELOLW\RIGHOLYHU\SRVLWLRQ Referral health centres and hospitals only: Comprehensive EmONC for any at risk pregnancies and any women with complications, including caesarean section and blood transfusion ‡(VVHQWLDOQHZERUQFDUH- resuscitation, drying the baby, warmth, kangaroo care for premature babies ‡Referral health centres and hospitals: PMTCT through antiretroviral therapy and safer infant feeding practices ‡5RXWLQHSRVWnatal care (PNC) for early identification and referral for illness as well as preventive care: ± For the baby: Promotion of healthy behaviours ± hygiene, warmth, breastfeeding and immunisation; danger sign recognition (e.g. fever, rapid breathing, poor feeding, floppy babies, colour change); early identification of illness and referral ‡([WUDFDUHIRUEDELHVZLWKRWKHUSUREOHPV HJPRWKHUVZLWK+,9$,'6 ‡([WUDFDUHRIORZELUWK weight (LBW) babies including Kangaroo Mother Care (KMC) ‡&DVHPDQDJHPHQWof neonatal illness especially sepsis & jaundice ‡(DUO\DQGH[FOXVLYHEUHDVWIHHGLQJIRUEDELHV Widespread availability of oral contraceptive pill, depo-provera, IUD, condoms, implants, tubal ligation (medically indicated)

RNI = Recommended Nutrient Intake

104

Health of girls & boys Prevention and treatment of STIs and HIV Reduction of gender based violence Gynaecological disorders Menstruation Neonatal tetanus Tuberculosis & polio prevention HIV

FGM & fistulas

Integrated plan for promotion of family planning and birth spacing at all levels Reproductive health education in schools Promotion of avoidance of early marriage and early pregnancy Condoms syndromic management of STIs free distribution of condoms Referral health centres and hospitals: care of victims of sexual violence , including PEP Prevention through awareness raising Referral health centres and hospitals: decrease unsafe abortion with D&C, MVA etc raise awareness of the availability of treatment of gynaecological disorders and encourage increased care seeking behaviour improve cleanliness, comfort and dignity of women during menstruation with free distribution and social marketing of sanitary towels in schools, shops and at certain public places 2 doses of tetanus toxoid for non-immunised pregnant women BCG & polio vaccine for newborns Referral health centres and hospitals: PMTCT Referral health centres and hospitals ART with low CD4 counts & nutrition counselling/support for pregnant women Referral health centres and hospitals: gynaecological care for women with complications of FGM, perineal tears and fistulas promotion of avoidance of FGM

105

Core programme 6 ± HIV, STIs and TB Standardised interventions by sub-programme Sub-programme

Interventions

Promotion of HIV prevention and decreasing stigma

Promotion at family & community level Promotion to decrease stigma Prevention services through behaviour change communication, display and dissemination of educational materials, provision of condoms, post-test clubs and community mobilization Promotion of use of condoms Abstinence, faithfulness education Prompt treatment of STIs Referral health centres and hospitals: Safe blood transfusion, with testing for HIV, Hep B & C, syphilis Sharps disposal; PEP for needle stick injury Single needle & syringe use policy HIV testing of pregnant women following national guidelines Regional hospitals: triple ART for HIV+ve pregnant women; Safe and quick delivery; HIV test & ART for at risk newborns; Syndromic management of STIs VCT encouraged for those with STIs Contact tracing Advice, prevention and care for high risk groups Referral health centres and hospitals: Counselling and testing; PEP for health workers. PEP for victims of sexual violence Social support Regional hospitals: - close collaboration between ART & TB centres CD4 testing and clinical monitoring (frozen samples sent to CD4 site Co-trimoxazole prophylaxis of P.carinii infection Treatment of opportunistic infections (e.g. antibiotics for pneumonia, oral re-hydration for diarrhoea, treatment of skin disorders, protozoa and fungal disease) Clinical assessment for TB Appropriate treatment of TB in line with national TB guidelines Manage severe HIV-associated conditions ART centres for people with HIV needing treatment, with adherence counselling and home-based care Manage severe side effects and toxicity of ARVs Support adherence with responsible care-givers Evaluate for treatment failure Inpatient care as necessary Promotion of appropriate foods Screening & referral for therapeutic care for severely malnourished Supplementary food for moderately malnourished Mass education and community education on signs and symptoms of TB Sputum testing Contact tracing Aim for > 70% case detection rate see EPI programme and HIV prevention Referral health centres and hospitals appropriate out-patient care following co-infection guidelines. Referral health centres and hospitals: appropriate out-patient and in-patient care. DOTS and responsible care-givers ± aim for 85% treatment success rate Referral health centres and hospitals: appropriate out-patient and in-patient care by TB teams of chronic bronchitis, bronchiectasis, pulmonary fibrosis, asthma

Prevention of sexual spread of HIV and STIs Prevention of blood borne spread of HIV

Prevention of maternal to child transmission Prompt treatment of STIs

Voluntary Counselling and Testing centres for HIV Treatment of people with HIV

Nutritional support for PLWHA Promotion of early detection and diagnosis of TB

TB prevention Management of TB ± HIV coinfection Multi-drug therapy for TB & leprosy Management of chronic respiratory illness

106

Excerpt E3: Essential Package of Health Services - the four service levels

Programmes at primary health unit level Core programme 1 ± Maternal, reproductive and neonatal health Sub-programme Promotion of maternal nutrition

Targeted supplementary feeding Promotion of neonatal nutrition

Care after birth

Family planning Health of girls & boys Prevention and treatment of STIs and HIV Reduction of gender based violence Menstruation

Neonatal tetanus Tuberculosis & polio prevention FGM & fistulas

Interventions Promotion of appropriate nutrition for pregnant & lactating women, girls & adolescents; MUAC screening and referral Antenatal - Iron/folate supplements for 6 months & Vit A 10,000iu once; or combined multiple micronutrient supplements, 1 RNI per day Postnatal ± Iron/folate supplements for 3 months; Vit. A 200,000iu once during first 6 weeks for mothers or MMN - 1 RNI58 each day Context specific, in liaison with MOH, WFP, UNICEF and agencies for acutely malnourished pregnant and lactating women promotion of immediate and exclusive breast feeding referral health centres/ hospitals: nutritional care of premature babies and term babies without a mother ± For the baby: Promotion of healthy behaviours ± hygiene, warmth, breastfeeding and immunisation; danger sign recognition (eg fever, rapid breathing, poor feeding, floppy babies, colour change); early identification of illness and referral - Early and exclusive breastfeeding for babies Widespread availability of oral contraceptive pill, depo-provera, condoms, Integrated plan for promotion of family planning and birth spacing at all levels Promotion of avoidance of early marriage and early pregnancy Condoms free distribution of condoms Refer victims of sexual violence Prevention through awareness raising improve cleanliness, comfort and dignity of women during menstruation with free distribution and social marketing of sanitary towels in schools, shops and at certain public places Two doses of tetanus toxoid for non-immunised pregnant women BCG & polio vaccine for newborns promotion of avoidance of FGM & prevention of fistulas with deliver in facilities

Core programme 6 ± HIV, STIs and TB Sub-programme Promotion of HIV prevention and decreasing stigma

Prevention of sexual spread of HIV and STIs Prevention of blood-borne spread of HIV Promotion of early detection and diagnosis of TB TB prevention

58

Interventions Promotion at family & community level Promotion to decrease stigma Prevention services through behaviour change communication, display and dissemination of educational materials, provision of condoms, post-test clubs and community mobilization Promotion of use of condoms Abstinence, faithfulness education Sharps disposal; Single needle & syringe use policy mass education and community education on signs and symptoms of TB see EPI programme and HIV prevention

RNI = Recommended Nutrient Intake

107

Excerpt E4: Health staff cadres Community Health Workers (CHW) Completed primary education and to have literacy and numeracy skills. Certified in a six-month training course. Community midwife Community midwives have been trained for at least one year in a certified nursing institute, and have previously completed primary education and have at least years two years of secondary education, with proven numeracy and literacy skills. Auxiliary nurse Auxiliary nurses have been trained for at least one year in a certified nursing institute, and have previously completed primary education and have at least years two years of secondary education, with proven numeracy and literacy skills. Registered nurse Registered nurse have had twelve plus years of primary and secondary education and have completed a certified nurse training course at an accredited nursing institution. Registered midwife Registered midwives have had twelve plus years of primary and secondary education and have completed a certified nurse training course at an accredited nursing institution. Anaesthetic assistants Anaesthetic assistants are nurses or health officers who have undergone six months of post-basic training in the use of simple and safe anaesthesia. Health/ Clinical officer training Health/clinical officers are registered nurses or midwives who have completed 18 months on certified post-basic training. Emergency obstetrics surgery diploma (nine months) An emergency obstetrics surgery diploma will be developed for training experienced general doctors, clinical officers and midwives, to do comprehensive emergency obstetrics and gynaecology such as Caesarean sections, D&Cs, MVA, ectopic pregnancies, tubal ligation, as well as interventions for APH, PPH and retained placentas. The completed training enables them to carry out comprehensive EmONC at referral health centre level and hospitals. Pharmacist training Drug-prescribing training Training for health staff in essential drug list and treatment guidelines applicable at each level: 1. 2. 3. 4. 5.

primary health unit level health centre level referral health centre level hospital level specialist drugs (e.g. TB, ARV, cardiac drugs, chronic disease management, tropical infections, anaesthesia).

108

W.Galbeed

Sanaag

Togdheer

Gabiley DH 11 MCH Awdal region (3 in Boroma) HGH

No

SRCS/Unicef

MCH Kulmiya

2009: Muslim Aid? None Private Diaspora

Private Private Private Private COOPI, UN agencies

COOPI, World Vision, SRCS Int.donors support (DFID, ECHO) Health Unlimited

COOPI Kijera Surgical camps

NGO supporting RH

Erigavo RH Manhal Community Hospital Erigavo Community H MCH Barwaaqo

Manhal Hospital Kaah Hospital Ugbad Hospital Agaweine Burao RH

Edna Adan MH

Boroma RH

Facilities

Awdal

Region

*assuming 300 working days/year

2007: 294 cases 1.ANC /year = less than 1/day* 198 cases repeat ANC = 0.7/day 109 cases 1.PNC = 0.3/day 2007: 527 1.ANC = < 2 /day 378 repeat ANC= 1.3/day 61 cases 1.PNC = 0.3/day

2007: 1472 ANC consultations (all)

4716/11= 429 facility/month = 1.5/day (2005)

No. ANC/PNC/time unit

No

No

2006: 319 deliveries 2008: 60 deliveries (pr. May 08) ?

2007: 1047 admitted for delivery = births

2006: 3169/ year

2006: 273 /year

366/year (2005)

No. deliveries /facility/time unit

ANNEX F: Obstetric care Somaliland: information as at January 2009

None

None

2006: 17% CS

146 (13.9%)

2006: 4%

2005: 25 (6.8%) 2006: 9% 2006: 4% None

No. CS/ % CS

Assist home deliveries

Normal deliv.p. Normal delivery point Normal delivery point Assist home deliveries

CEmOC BEmOC BEmOC CEmOC CEmOC

CEmOC

BEmOC (2008) Normal delivery point CEmOC

CEmOC

Level of functioning

109

UNFPA 2008

UNFPA 2008

UNFPA 2008

UNFPA 2008 UNFPA 2008

UNICEF/UNFPA UNICEF/UNFPA UNICEF/UNFPA UNICEF/UNFPA MOHL 2006

Hospital statistics Edna Adan Mat. H

MOHL 2006

MOHL 2006 MOHL 2006

MOHL 2006

Source

Lasanood Hospital Berbera H

Public COOPI (HIV only)

SRCS/Unicef

1234 3139 2770* 319 273

Boroma RH Hargeisa GH Burao RH Gabiley RH

1076 (87) 2963 (90) 2730 (98.5%) 264 (78%) 258 (95%)

Normal deliveries (%)

106 (9%)* (4%) 117(4.2%)* (17%) -

No. CS (%)

4 (1%) (2%) 42 (1.5%)* (6%) -

No. ass.vag. delivery**

-

3% -

8 (1%) 0 0 7 -

Maternal deaths (of admissions) 200 + 117 (4.2%)*+? 4 + 3 + 50 ?+5+?

Neonatal deaths + stillbirths+ IUFD

-

15% -

% birth coverage region (liveborn)

None

None

-

1% -

% CS all expected deliveries region

BEmOC CEmOC

Assist home deliveries

Assist home deliveries

* Boroma has a surgical team from Kijabe, Kenya, with intensive clinics; this drives up numbers. Normal activity 2-3 CS per month (assessment UNICEF, 2008). ** Includes vacuum + forceps delivery.

All deliveries

Facility

Source: Somaliland MOHL Annual Report 2006/07* Abortions (of admissions)

2007: 585 cases 1.ANC = 2/day 290 cases repeat ANC 61 cases 1.PNC = 0.3/day 2007: 673 cases 1.ANC = 2-3/day 358 cases repeat ANC = 1.2/day 126 cases 1.PNC = 0.5/day

Examples of quality and quantity of care at EOC facilities

Sool Sahil

MCH Gal Adaq

MCH Eel Afwaine

-

110

Awdal 0.2% --

Maternal deaths region (liveborn)

UNFPA 2008 UNICEF/ UNFPA 2006

UNFPA 2008

UNFPA 2008

Sool

Sanaag

Mudug

Nugaal

Bari

Region

-

Bossaso RH Quardho H 4 MCH Nugaal GH (Garowe) MCH (2) Galcayo Medical Centre Erigavo RH

Facilities

-

None

Unicef UNFPA

AAH SC/UK IFRC/SRCS/Unicef IFRC

NGO supporting

--

6/day/facility (2008)

No. ANC/PNC /time unit

>500

No. deliveries/facility /time unit 548/year (2007?) 350/year no

-

-

2007: 40/month

104 (19.0%)

No. CS/ % CS

No EmOC

No EmOC

CEmOC

CEmOC

Level of functioning CEmOC CEmOC

111

UNFPA 2008 UNFPA 2008

UNICEF UNFPA

MOHL 2006 MOHL 2006 IFRC UNFPA

Source

ANNEX G: Obstetric care in Puntland: information as at January 2009 - 4 hospitals + 47 MCH

COOPI SOS Kinderdorf

IMC

Baidoa RH

Baidoa: MCH

MCH

Banadir

M.Shabelle

Bakool

Wajid Hospital Huddur Jowhar Reg. H. Jowhar Hospital Maternity Hospital Merka Regional Hospital SOS Kinderdorf

MSF Swiss

Dinsoor H

Bay

Hiraan

Galgaduud

SOS Kinderdorf

COSV

MSF Belgium Intersos COSV MSF Spain

MSF Belgium CCM CISP MSF Swiss

Harardere DH Hospital Galcayo South Dhuusamareb (Istarlin Hospital) Eldere DH Belet Weyne H

Mudug

Unicef/ MSF Spain/ IMC/COSV/MDM/ Muslim aid/ SRCS/ Dawa-al-Islam/IIRO/ ZamZam/ local NGOs/ private facilities/ MOH-facilities CISP MSF Holland

NGO supporting

MCH offering ANC, PNC, some normal delivery points; a few can perform some BEmOCfunctions.

Facilities

All

Region

194 ANC/month (2008)

22 ANC/day

No data

Variable

No. ANC/PNC/time unit

110 / month (2008)

209 /year (2007-Halima)

262 /year (2007?)

50-80 /month

?

Variable

No. all deliveries/facility/time unit

ANNEX H: Obstetric care in Central South Zone as at January 2009

17 (

41 (19.6%)

11 (4.2%)

Ventouse, forceps

4-5/month 21/month (510%)

4-5 /month None

No

No. CS/ % CS

CEmOC

CEmOC

BEmOC + blood CEmOC CEmOC CEmOC

BEmOC (-)

BEmOC + blood

BEmOC + blood

CEmOC CEmOC

CEmOC

CEmOC BEmOC + blood

Normal delivery points

Level of functioning, January 2009

112

SOS Kinderdorf

WHO 2008

CISS MSFB 2008 CISS COSV 2008 CISS

COSV 2008 MSFCH 2008 MSFCH 2008 COOPI 2008 SOS Kinderdorf 2008 IMC 2008

MSFB 2008

COSV 2008 MSFH 2008

CISS

Source

Middle Juba Lower Juba

Gedo

L.Shabelle

2008: 1753/y = 5.8/d

CEmOC

BEmOC

BEmOC

Muslim Aid

5 CS (1.part 2008) 2 CS (1.paer 2008)

1 CS (1.part 2008)

BEmOC + blood

11 obs.compl/year

37 obs.compl.year

55 obs.compl/year

BEmOC CEmOC CEmOC BEmOC

107 /year (2007)

No CS

CEmOC

83 /year (2007)

MSF Belgium Private

2008: 1660/y = 5.5/d

Garbahare H

Marere Hospital Kismayo Hospital MCH

2008: 2209/y = 7.4/d

Private Private (Hayat MG) GHC

COSV

CEmOC CEmOC CEmOC CEmOC

ICRC Ministry of Health MSF France Private

30 CS/month

CEmOC

CEmOC

CEmOC? Private (Hayat Medical Group) ICRC

Luuq Hospital

Keysaneh Hospital, Mogadishu Medina Hospital Banadir Hospital Daynille Hospital Arafat Specialist Medical Hospital Hospital Quoryolei Hospital Brava Hawa Abdi Hayat Hospital Bullahawa Hospita

Afgoye - private hospital Hayat Hospital

113

Muslim Aid 2008

MSFB 2008 CISS

GHC 2008

GHC 2008

COSV 2008 CISS CISS GHC 2008

COSV 2008

ICRC CISS CISS CISS

ICRC

CISS

2008 CISS

Awdal

CCBRS

COOPI

59

W.Galbeed

Sahil Support HGH: CEmOC In IDP areas: 5 MCH: BEmOC 75 TBAs

Burao RH: technical and fin.ass. 6 MCH

HMIS Training midwife, nurse and TBA tutors In-service training Community sensitization and awareness of RH for IDPs Boroma RH: technical and fin.ass.

Support 68 MCH with kits+ equipment

Supply RH-kits, essential med & surgical equipment (kit 6,7,9,10,11), clean delivery kits, hygiene kits, TBA assistance kits to MOHL and Somali partners Support CCBS in training midwives Support training 22 community midwives (18 months Edna MH)

Delivery care /ANC/PNC

Only HIV/AIDS activities directly related to RH, such as PMTCT, are included.

Health Unlimited

Several regions W.Galbeed

WHO

Togdheer

All

W.Galbeed

Several locations

Location

UNICEF

UNFPA

Agencies

Source: NGOs/UN-agencies

a) Somaliland - 18 hospitals and 68 MCH

FP services

Distribution FP kits with pills, male condoms, inj.

Family planning

Boroma RH: Support PMTCT+ARV Burao RH: Support PMTCT+ARV Berbera H: Support PMCTC + ARV SGBV

Consultants MOHL(gender, HIV)

2008: Support 47 cases fistula op. Boroma RH

Other RH activities59 Advocacy campaign fistula

ANNEX I: Reproductive health activities by implementing partners, 2007/08

Not started yet

Q. midwives training

GAPS

114

Awdal

MOHL

60

Sool Sanaag

HGH: CEmOC Alaale Hospital: CEmOC Erigavo Hospital: normal delivery point MCH for IDP in Hargeisa at community level 2 MCH 3 MCH MCH + outreach MCH C.Weyne hospital : CEmOC Edna Adans Maternity Hospital: CEmOC Kaah Hospital: BEmOC Ugbad Hospital: BEmOC Agaweine: CEmOC Lasanood Hospital: BEmOC Sirad/Aden Mire Hospital (= Manhall?)

Technical support MOHL: 1 MD 2009: Start RH-activities Hargeisa 1 MCH

Delivery care /ANC/PNC

Only HIV/AIDS activities directly related to RH, such as PMTCT, are included.

Private

Sanaag W.Galbeed Togdheer Togdheer Awdal W.Galbeed W.Galbeed

W.Galbeed

Muslim Aid

Progressio SC/UK SRCS World Vision

W.Galbeed

Location

Merlin

Agencies

Family planning

Enrol fistula cases by outreach

Other RH activities60

Erigavo H for 2009?

GAPS

115

Nugaal

IFRC

61

Bari

HMIS Support hospitals 2008: Distribution of clean delivery kits with UNFPA. Nugaal GH: MDs salaries+ drugs/surgical equipment/rehab 8 MCH + 1 mobile 6 MCH + 1 mobile 4 MCH Bossaso

Bossaso RH: EmOC equipment and drugs. Support MCH with kits+ equipment

Only HIV/AIDS activities directly related to RH, such as PMTCT, are included.

SRCS/IFRC

All Nugaal

WHO Islamic relief

Mudug

All

Bari

Garrowe RH: EmOC equipment and drugs.

Galcayo Medical Centre: 2007: midwife training 2008: CEmOC for MDs

Mudug

Nugaal

Supply RH-kits, essential lab, med &surgical equipment (kit 2,4,5, 6,7,9,10,11), clean delivery kits, hygiene kits, TBA assistance kits to MOH and Somali partners.

Delivery care /ANC/PNC

Several locations Puntland

Location

UNICEF

UNFPA

Agencies

-

No FP

1 workshop FP

UNFPA: Kit 4+5

Supply Kit 4 (pills + inj.) to MoH ± distributed to KRVSLWDOVELJ0&+¶V

Family planning

TBA training

2008:Galcayo Medical Centre: trainings on SGBV, EmOC + fistula surgery Support to rapid test

Other RH activities61 Supply PEP-kits Advocacy fistula campaign in Garowe Stakeholders forum for RH.

Source: NGOs/UN-agencies. No international NGOs in Puntland. No RH information gathered from private hospitals or local NGOs.

4 hospitals + 47 MCH

b) Puntland

116

No FP. Not complete BEmOC

CEmOC, no FP Surgeon left during latter part of 2008?

No FP in kits No oxytocine

No information on use of FP commodities.

GAPS

Several

WHO

Eldere DH:CEmOC 4 MCHs: normal deliveries 6 HP Harardere DH: CEmOC, 3 MCHs: normal deliv. Baidoa RH: Established BEmOC +Rehab. 14bed maternity No CEmOC from June-08

Supply 130 MCH with kits + equipment for ANC/PNC/normal deliveries HMIS 130 MCH Consultant surgeon assessment, training EOC surgery in x facilities Wajid Hospital: Hospital 1 MCH + 1 HP Dhuusamareb: Istarlin Hospital

Baidoa RH: CEmOC: Salary gynaecologist Baidoa RH for 2008 TBA trainings 2007

Supply RH-kits, essential med &surgical equipment (kit 6,7, 9,10,11), examination beds, clean delivery kits and hygiene kits, TBA assistance kits to implementing partners

Delivery care /ANC/PNC

Only HIV/AIDS activities directly related to RH, such as PMTCT, are included.

Mudug Bay

COOPI

62

Galgadud

AMISOM CCC CCM (m/MSFB) CISP

Bakool Banadir Bay Galgadud

All

Banadir

Bay

Several regions

Location

UNICEF

UNFPA

Agencies

Source: NGOs and UN-organizations

Only male condoms

No

Supply pills, inj. + male, condoms (Kit 4+5)

Family planning

HIV-test, syphilis test, HCV-test

Other RHactivities62 Advocacy campaign fistula

21 functioning somatic hospitals (total 23) + 118 (UNICEF) /87 (WHO) MCH/OPD/ 129 MCH (UNFPA)

c) Central South Zone

117

No CEmOC since latter part of 2008 due to lack of staff

FP

Gynaecologist left June 2008.

Current GAPS

Banadir Bakool (3), Hiraan (2), Bay, Lower Shabelle

M.Shabelle

IIRO (int) IMC

Intersos

1 MCH Jowhar

Jowhar Regional Hospital: 20 mat.beds: CEmOC

MCH Mogadishu 8 MCH: normal delivery, ANC,PNC Outreach ANC/PNC TBA trained, supplied w /kits. Support HP w/TBA

2 MCH MCH Mogadishu: Keysaney Hospital: CEmOC Medina: Medina Hospital: 100 beds: CEmOC

8 MCH/OPD: ANC/PNC 51 HP Belet Xawa DH: CEmOC 2007 Luuq DH: CEmOC 2007 Garbahare DH: CEmOC 2007

TBA training 2007 3 MCH 2 MCH

13 MCH Baraawe (Brava) DH :CEmOC Quoryolei DH: BEmOC Merca RH: CEmOC: 12 maternity beds

Delivery care /ANC/PNC

Only HIV/AIDS activities directly related to RH, such as PMTCT, are included.

Hiraan M.Shabelle Banadir

GOHED HSHORO ICRC

63

Gedo

Gedo Banadir

Banadir

L.Shabelle

Location

Dawa AlIslam (int) Gedo HC

COSV

Agencies

Pills, male condoms

No FP

No pills, Depot, IUD, implants

Family planning

SGBV assessment, training and advocacy VCT. Training HR in HIV

Other RH activities63

118

Both Free services Medina: 30 CS/month Low attendance 6 MCH closed Sept 08. No realistic referral

No referral. 2008: No CEmOC due to lack of staff No FPconsultations in 2008

Insufficient FP

Current GAPS

Middle Juba

MSF Holland

Only HIV/AIDS activities directly related to RH, such as PMTCT, are included.

Hiraan Bay L.Shabelle

MSF Swiss

64

Banadir M.Shabelle

MSF Spain

Banadir

Lower Juba

Mudug

Galgaduud Banadir

MSF France Marere DH: CemOC until beg. 08. Now BemOC + blood Galcayo South: CemOC until beg. 08. Now BemOC + blood Kismayo H: CemOC until beg. 08. Closed since Jan 08. Mogadishu: 1 MCH with ANC/PNC until Jan 08. Closed. 1 MCH Jowhar Maternity Hospital :CEmOC 4 MCH Belet Weyne H: CemOC 17 maternity beds Dinsoor H: BEmOC + blood. CEmOC until 08 2 MCH

Dusa Mareb H: CemOC Daynille Hospital: CEmOC

Bay Bakol

MSF Belgium

Ministry of Health

MCH Adale 4 MCH 2 MCH, 6 HP MCH Belet Weyne 1 MCH Jowhar MCH Banadir Hospital: CEmOC Banadir Mother and Child Hospital: MCH BuurHakaba Hospital Huddur H: BEmOC + blood

M.Shabelle Hiraan Galgaduud Hiraan M.Shabelle M.Juba Banadir

Medair Mercy-USA Merlin Mercy USA

2 MCH (from COSV 2008): 1 normal deliveries

Delivery care /ANC/PNC

L:Shabelle

Location

MDM

Agencies

Pills, male condoms

FP

Pills, male condoms, injectables

Pills, male condoms FP

Pills, male condoms

Family planning

2007: Fistula camp

Other RH activities64 No FP

119

No Depot-Provera No realistic referral

No CemOC due to lack of staff

No CemOC No realistic referral

Small fees

Free

Current GAPS

65

MCH

Hayat Hospital: 100 bed, CEmOC Hospital: CEmOC Hawa Abdi: private hospital: CEmOC

2 MCH MCH Medina 1 MCH 2 MCH 2 MCH MCH Arafat Specialist Medical Hospital: CEmOC Al-Cimraan Hospital: MCH Ayan Hospital: CEmOC before occupied

Delivery care /ANC/PNC MCH: CEmOC 1 MCH Medina: normal deliveries 2 (4?) MCH : normal deliveries MCH 1 MCH 1 MCH MCH Mogadishu SOS Hospital Mogadishu: CEmOC+ 1 MCH. 200 norm.deliv/month Afgoye: Satellite clinic: normal deliveries, ANC Baidoa: MCH 27 MCH/OPD + 5 for IDPs: ANC/PNC

Only HIV/AIDS activities directly related to RH, such as PMTCT, are included.

Diverse org.

Hayat MG

Banadir L.Shabelle L.Shabelle

M.Shabelle Banadir Banadir Bay Bakool Banadir Banadir

SSRDA (local) SSRDO World Vision

ZamZam (int) Private

All

Bay

Location L.Juba Banadir L.Shabelle Hiraan M.Shabelle M.Shabelle Banadir Banadir

SRCS/ICRC

SAACID (l) SHARDO (l) SIFA (local) SOS Kinderdorf

Agencies Muslim Aid

Presently closed

None

Offer FP

Family planning None

Gynaecologist Dr. Hawa

TBA trainings

Other RH activities65

120

Muslim Aid taking over?

All charge fees

No FP. Far to go to become BEmOC Not equipped for normal deliveries

Free

Current GAPS Not free services No FP? Received supplies

ANNEX J: SGBV/FGM: Lessons learned and best practices Source: Female Genital Mutilation/cutting in Somalia, WHO 2005.

A successful anti-FGM/FGC movement must have the following six basic foundations: Strong and capable institutions implementing anti-FGM/FGC programs at the local, national and regional levels. A committed government which supports FGM/FGC eradication with positive policies, laws and resources. Institutionalization of FGM/FGC in national reproductive health, education/literacy and development programs. Trained staff that can recognize and manage the physical, sexual and psychological complications of FGM/FGC. Coordination among governmental and nongovernmental agencies at the local, national, regional and international levels. An advocacy movement, which fosters a positive political and legal environment and increases support for programs and public education

IASC Guideline for medical care of victims of SGBV Source: Inter-Agency Standing Committee (IASC) - Guidelines for Gender-Based Violence Interventions in Humanitarian Settings.2005 (www.humanitarianinfo.org - accessed January 15th 2009)

Minimum treatment for survivors of sexual violence as per the IASC Guidelines Prepare the survivor by explaining what examinations will be done and obtain consent (from the survivor or from parent/guardian if survivor is a minor). Perform a physical examination and address any symptoms of panic or anxiety. Provide compassionate and confidential treatment, including: - treatment of life-threatening complications and referral if appropriate - presumptive treatment of STIs - post-exposure prophylaxis for HIV where appropriate - emergency contraception - care of wounds - supportive counselling - discuss safety issues and make a safety plan - PDNHUHIHUUDOVZLWKVXUYLYRU¶VFRQVHQWWRRWKHUVHUYLFHV Collect minimum forensic evidence for legal redress, in case evidence can be processed.

Situation Analysis Reproductive Health - Somalia

April 2009

ANNEX K: Organizational structure of the Ministry of Health and Labour for the three zones

1. Somaliland

122

Situation Analysis Reproductive Health - Somalia

April 2009

2. Puntland

123

Situation Analysis Reproductive Health - Somalia

April 2009

3. Central South Zone (TFG)

124

Situation Analysis Reproductive Health - Somalia

April 2009

ANNEX L: Maternity waiting shelters Source: WHO, 2005

Maternity waiting shelters: The purpose of maternity waiting homes is to provide a setting where high-risk women can be accommodated during the final weeks of their pregnancy, near a hospital with essential obstetric facilities. Some maternity waiting homes have expanded their purpose to include not only decreased maternal mortality but also improved maternal and neonatal health. In these homes, additional emphasis is put on education and counselling regarding pregnancy, delivery and care of the newborn infant and family. The first maternity waiting homes were intended for women with major obstetric abnormalities for whom operative delivery was anticipated but whose homes were in remote and inaccessible rural areas. Gradually the concept has been enlarged to include "high risk" women, including those expecting their first delivery, women with many previous births, very young women, older women, and those identified as having problems such as high blood pressure during pregnancy. At first glance the concept of maternity waiting homes is attractive in many ways. It does not require high technology; it relies mostly on human resources already present in many communities; and it can serve as a practical way to meet the needs of pregnant women. However one must remember that maternity waiting homes are not merely physical facilities and they cannot function effectively in a vacuum. Rather, they are a link in a larger chain of comprehensive maternity care, all the components of which must be available and of sufficient quality to be effective and linked with the home. Success in actually safeguarding pregnant women's health depends largely on what happens outside the maternity waiting home. A maternity waiting home is not a stand-alone intervention, but rather serves to link communities with the health system in a continuum of care. The level of success in reducing maternal and infant mortality will depend on the following factors: 1) Definition of risk factors and selection of women; 2 ) viable community level health service necessary for referral to occur and women's compliance with the referral; 3) skilled obstetric services (including capacity to handle obstetric emergencies); and 4) community and cultural support. These constitute the essential elements of a maternity waiting home. Careful consideration of these crucial elements raises a number of problems and issues which must be resolved before setting up a maternity waiting home.

125

Situation Analysis Reproductive Health - Somalia

April 2009

ANNEX M: Terms of Reference - Consultant Reproductive Health Duration: 3 months Nov 24th 2008 ± March 2nd, 2009.

Objective: The objective of this assignment is to work in close collaboration with DFID consultant and UNICEF, UNFPA and WHO technical staff to develop a reproductive health strategy and plan of action based on RH needs identified through a comprehensive analysis.

Terms of Reference: Working closely and in collaboration with the DFID and UNICEF and zonal RH focal points of UNFPA and WHO, the consultant will; 1. Carry out reproductive health needs assessment through literature review and mapping of ongoing interventions in reproductive health including services provided by private sector and NGOs 2. Identify gaps and opportunities in RH programming both geographically to assess equity issues as well as in different areas of reproductive health including family planning 3. Conduct mapping of human resources for RH by zone, including nurses, midwives, TBAs and doctors 4. Assess availability of finances for RH and conduct a gap analysis 5. Define priority areas of intervention for each zone in consultation with the health authorities and other partners 6. Develop a comprehensive national reproductive health strategy and a plan of action 7. Assist in organizing workshops to share the strategy with health authorities and get their endorsements 8. Assist in developing a joint project proposal to be included in United Nations Transition Plan and work closely with donors to identify funding opportunities 9. Work as WHO focal point for RH working group to coordinate various interventions and ensure alignment and linkages with health partners

Deliverables: 1. A detailed situation analysis of existing status of RH needs and availability, accessibility of RH services in both public and private sector 2. Draft National Reproductive health strategy and a plan of action

126

The international community and Somali authorities have committed to make progress towards reaching the MDGs by 2015 in Somalia. Despite major new efforts to reduce mortality among young children (MDG4) little has been done to systematically reduce maternal mortality (MDG5). The Maternal Mortality Ratio in Somalia remains one of the highest in the world (1,400/100,000 live births) – yet a recent study indicated extremely low and unpredictable financing of efforts to ensure adequate services for reproductive health and reduction of maternal mortality. Concerning maternal and neonatal health, more than 90% of women deliver at home and more than half are assisted by a traditional birth attendant. Access to skilled delivery care and emergency obstetric care is extremely low especially among rural and nomadic populations. There are considerable unmet needs in all major fields of reproductive health. Due to years of war, conflict and lack of an effective government, the health system is fragmented, highly privatized and underperforming, and suffers from major deficiencies in basic funding, qualified human resources, management mechanisms and reliable data for planning. Besides, there are strong socio-cultural values, norms and beliefs which affect attitudes and behaviours towards sexual and reproductive health, especially reproductive rights and demand for services. The needs are high but the solutions are not evident. In collaboration with Health Authorities, the UN agencies determined the need for a systematic effort to approach reproductive, maternal and neonatal health. The first step was to commission a major review of all information available on reproductive health in Somalia – to provide the best evidence available in which to ground development of policies and plans of action – and raise awareness. This report presents the findings of the situation analysis. This situation analysis has been the main source document for subsequent efforts to draft policy documents and a national strategy and action plan (2010 – 2015).

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