Human Resources for Health in Crisis: A case of Somalia/ Somaliland

1. HUMAN RESOURCES FOR HEALTH IN CRISIS; A
CASE OF SOMALIA/ SOMALILAND
By WARIO GALMA
COUNTRY DIRECTOR
THET SOMALIA

2. Fragile States
■ The unique challenge
■ ‘Fragile sates present unique challenges to health care
systems, whether through increased burden of
disease, conflict, scarcity of health care workforce,
financial limitation, fragile governance or weak
institutional leadership’ (From Benton e.al (2014)
■

3. SOMALILAND AND SOMALIA

4. Somalia/ Somaliland
■ Somalia is transitioning from a two decade long complex emergency and civil conflict.
■ Estimated 1.1m refugees in neighboring countries and 1m internally displaced persons(IDPs)
estimated.
■ Destruction of health infrastructure and health system – challenges to health workforce
■ Somalia has an estimated population of 10,787, 000 / Somaliland 3,500,000 (60% women)
■ Under-five and maternal mortality in Somalia and Somaliland are amongst the highest in the world
- A woman’s life-time risk of dying due to pregnancy related causes is approximately 1in 14.
■ Common causes of the under -5 mortality are: Pneumonia 24%, Diarrhea 19%, Measles 12%.
■ Both are drought prone and face food insecurity, which is exacerbated by poor health care, lack of
access to safe drinking water and safe sanitation.
■ FGM/C is almost universal and is performed on young and adolescent girls.
■ It is estimated that almost one million children under-5 are acutely malnourished, of which more
than 40% are severe cases.
■ It is estimated that at least one person has some form of mental illness in every two households in
Somaliland - Nationally, 21% of Somali households care for at least one family member with
severe mental health problem.
■ Over 50% live in the urban centres constituting mainly internally displaced persons (IDPs) and
pastoral drop-out due to conflict and cyclic drought.
■ Over 65% of the population are youth
■ Access to maternal health services is low with 44 and 38 % of births in Somaliland and Puntland
being attended by skilled birth attendant (SBA)
■ The contraceptive utilization rates are estimated at only 1 % and over 25% of women have an
unmet need for family planning

5. Human Resources for Health
■ The World Health Organization(WHO) defines Human Resources for
Health (HRH) as ‘’ all people engaged in actions whose primary
intent is to protect and improve health’’. According to this definition,
health workers include:
■ Those delivering direct services to a target population and are hence
dented as ‘’health service providers’’ and
■ Those not directly engaged in the provision of services, but providing
managerial and support inputs to the national health system
■ HRH domain also incorporates the technical skills and expertise that
health workers apply when performing the promotive, preventive,
curative and rehabilitative services of the health system.
■

6. Global standards on Human
Resources for Health
■ Human resources for health play a pivotal role in the accessibility of
health services and the overall population health of the country. Specific
benchmarks exist’ for government and development partners to ascertain
whether or not a country faces a health workforce crisis.
■ Health workforce density is the most widely used indicator. The World
Health Organization (WHO) has set a density indicator of 2.3 health care
professionals per 1000 population as a minimum threshold for public
health access. Countries with densities lower than this are defined as
having a critical shortage of health workers.
■ Cumulatively the Somali health authorities have a physicians’ density of
about one per population of 20,000, while the nurses and midwives have
a density of about four and one per population of 20,000, respectively.
■ Somaliland has 0.82 density health care professionals per 1000
population which is far below the minimum WHO threshold.

7. Health workforce in Somalia/ Somaliland
■ Two decades of civil conflict – destroyed most public sector higher medical
education and middle-level training institutions – resulting in severe health worker
shortage:
– Cumulatively the Somali health authorities have a physicians’ density of about
1/20,000, 4/20,000 for nurses and 1/20,000 for midwives.
■ Inadequate and uncoordinated Continuous Professional Development for health
workers.
■ Grossly understaffed, poorly equipped medical education faculties
■ Rise of private unregulated medical colleges and health professional training
institutions
■ Lack of established and capacitated regulatory bodies/ institutions for regulating
norms, accreditation, standards and governance control measures.
■ Severely constrained delivery of quality health services and limited workforce
productivity.
■ Glaring HRH disparities between the urban and rural
■ Weak/ absence of comprehensive HRH information system
■ Limited budgetary allocation to the public health sector
■ Weak strategic coordination among stakeholders/ partners, innovative and
collaborative HRH endeavors with a view to accelerating the progress towards
Universal Health Coverage (UHC) and the attainment of the post-2015 health
related Sustainable Development Goals (SDG)

8. Somalia/Somaliland Health Stakeholders'
Partnerships and Coordination
Ministries of Finance
Ministries Responsible for
Higher Education
Regional and Local
Governments
Health Professional
Associations
The private Sector
Communities & their
Representatives
 International
Partners:
 UN Agencies
 International NGOs
 Donor PartnersPublic Health

9. HRH challenges and access to services
■ Damaged physical structures due to two decades’ conflict.
■ Insecurity that reduces the ability to attract investment and skilled workforce.
■ Acute shortage of trained and qualified health professionals and inadequate skill mix and task shifting.
■ A significant dichotomy of health workforce between rural and hard to reach areas and the urban facilities
■ Lack of diagnostic medical technology and equipment’s and capacity to maintain those that exist.
■ Scarcity of financial resources to cover HRH employment needs
■ Poor HRH workforce strategic plan implementation; JDs, trainings, programme needs, recruitment, deployment,
appraisals, distribution, qualification, motivation and National HR policy.
■ Weak quality and reliable health information systems – Ghost workers, underage, lack of data on numbers,
condition of health facilities, demographic data
■ Weak policy making and implementing structures/ institutions.
■ Donor driven/ sourced reconstruction influenced by external factors without limited recipient county control that
may not be aligned to local priorities, MOH playing stewardship role.
■ Absence/ weak regulatory
■ Lack of focus on mid-level professional training:
■ Shortage of mid-level health workforce to serve underprivileged remote and hard to reach geographical areas.
■ Disparity between production and demand:
■ Abrupt phase-out of the support by International NGO’s due to insecurity or end of the project life-span.
■ Inadequate and effective utilization of human and financial resources; working partnership (coordination/
collaboration) with multilaterals, Bilateral, UN agencies NGOs, private sector and the local Authorities.

10. THET, KINGS & Regional Stakeholders
Contribution
■ Training of frontline health workers (Nurses, midwives, lab
technicians, CHW)
■ Training of nurses and doctors on BEmONC and CEmONC
■ Support to internship programme
■ Support tutors training on teaching methodologies and
leadership
■ Leadership, governance and management of middle level and
senior health workers.
■ Support MOH on development of relevant polices
■ Support medical Faculty development
■ Support provision of teaching and learning materials (Skill labs)
■ Working Health Professional Association and regulatory bodies.

11. Key HRH intervention strategies
■ Human Resources production & training
■ HRH planning, deployment, utilization and management
■ Human Resources for Health Policy
■ HRH financing and Funding sources diversification.
■ HRH Regulatory framework
■ Creating Mechanisms for HRH Retention:
■ HRH Information System and Research:
■ Building HRH Governance, capacities, partnership and
coordination:

12. Lessons
■ Training of TOT promotes local knowledge and sustainability.
■ Online training by Kings/ MA valuable in upscaling new knowledge and
skills as well as reaching insecure locations.
■ Challenges of reaching larger target by volunteers due to security risks.
■ Donor/ international NGO driven policy development not implemented.
■ Donor dependency with limited commitment on increasing the Health
Sector Budget.
■ Donor driven agenda that may not necessarily aligned with the
population/ host government priorities (Not paying Health workers
salaries).
■ Unstainable project with heavy funding and once project comes to an end
health worker can be sustained - Difference in salaries/ allowances.
■ Weak and ineffective coordination