Andrew Leather, Edna Adan Ismail, Roda Ali, Yasin Arab Abdi, Mohamed Hussein Abby, Suleiman Ahmed Gulaid, Said Ahmed Walhad,Suleiman Guleid, Ian Maxwell Ervine, Malcolm Lowe-Lauri, Michael Parker, Sarah Adams, Marieke Datema, Eldryd Parry
In 1991, the Somali National Movement fighters recaptured the Somaliland capital city of Hargeisa after a 3-year civil war. The government troops of the dictator General Mohamed Siad Barre fled south, plunging most of Somalia into a state of anarchy that persists to this day. In the north of the region, the redeclaration of independence of Somaliland took place on May 18, 1991. Despite some sporadic civil unrest between 1994 and 1996, and a few tragic killings of members of the international community, the country has enjoyed peace and stability and has an impressive development record. However, Somaliland continues to await international recognition. The civil war resulted in the destruction of most of Somaliland's health-care facilities, compounded by mass migration or death of trained health personnel. Access to good, affordable health care for the average Somali remains greatly compromised. A former medical director of the general hospital of Hargeisa, Abdirahman Ahmed Mohamed, suggested the idea of a link between King's College Hospital in London, UK, and Somaliland. With support from two British colleagues, a fact-finding trip sponsored by the Tropical Health and Education Trust (THET) took place in July, 2000, followed by a needs assessment by a THET programme coordinator. Here, we describe the challenges of health-care reconstruction in Somaliland and the evolving role of the partnership between King's College Hospital, THET, and Somaliland within the context of the growing movement to link UK NHS trusts and teaching institutions with counterparts in developing countries.
The health sector in a post-conflict country can be severely limited by three factors: 1) a total absence of central government funding for health; 2) a disintegrated system of health care; and 3) a void in teaching and training of all cadres of health workers dating back to the preconflict era. The effect of these issues in a developing country already struggling with the usual health challenges, including high maternal and child mortality, poor access to health services, and infectious diseases such as malaria, tuberculosis, and HIV, is even more devastating. Somaliland is one such country.
The former British Somaliland Protectorate attained independence on June 26, 1960. 5 days later, Somaliland merged with the former Italian-administered United Nations Trust Territory of Somalia to form the Somali Republic. The dream to unite all Somali people in the Horn of Africa under one sovereignty was thwarted by several events: the independence of Kenya in 1963; the loss of ethnic Somali people to Ethiopia in 1964 and 1977-78; and when French Somaliland became the Republic of Djibouti in 1977. 9 years of parliamentary civilian rule of the Somali Republic ended with the assassination of the president on Oct 21, 1969. The military dictator, General Mohamed Siad Barre, took control and established a regime of so-called scientific socialism.
The mainly Isaac tribe of the former northwest area of Somaliland suffered greatly under Siad Barre, and their struggle led to the formation of the Somali National Movement in London in 1981. The Isaacs clan live mainly in Somaliland and were targeted by the government of Somalia and the Siad Barre regime because they were fighting for the freedom of Somaliland. A major offensive by the movement against government positions in May, 1988, was followed by a 3-month government bombardment of the north of the region. Planes took off from Hargeisa airport to bomb the townspeople of the same city. These raids resulted in almost total destruction of the capital. More than 500 000 people fled to Ethiopia and at least 50 000 died during these attacks.1 However in 1991, the Somali National Movement recaptured Hargeisa and the government troops fl ed south, leading to the redeclaration of independence of Somaliland on May 18, 1991. A slow and painful process of recovery was launched.
Today, most people have returned from the refugee camps, and generally they live in simple huts in camps around Hargeisa. The economy relies on the livestock trade, which accounts for about 40% of the gross domestic product and 60% of export earnings.
Remittances from the Diaspora (the body of Somalilanders living outside the country) provide aid for many Somalis: these are received mainly by urban households, and in Hargeisa there are more than 20 money-transfer companies and 50 internet companies 2 providing support to about 120 000 recipient households.3
Somaliland is at present building a society founded on peace, justice, and the rule of law. In December, 2002, the first local government elections were held, followed in April, 2003, by the first presidential elections, which were peacefully contested by three political parties-UDUB, UCID, and KULMIYE. On May 14, 2003, the national electoral commission and the supreme court of Somaliland confi rmed the simple majority of the UDUB party, after which President Dahir Rayale Kahin and Vice President Ahmed Yussuf Yassin were sworn into office for a 5-year term. Furthermore, legislative elections took place in Somaliland in September, 2005. A 76-strong team of observers from the UK, Canada, Finland, Kenya, South Africa, the USA, and Zimbabwe monitored the polls and issued a statement that the elections were undertaken in a peaceful atmosphere and were generally free and fair. Health indicators for Somaliland are some of the worst in the world and are poor even in relation to other countries in sub-Saharan Africa (table 1). Key issues in the health sector include a chronic shortage of qualified health professionals, poor governance, and few resources to finance the health service. The inability of the government to pay adequate salaries for health workers greatly hampers the rebuilding of capacity in hospitals and health centres throughout the country.
UK response from the Tropical Health and Education Trust and King's College Hospital
Faced with the size of these challenges, to see how a small group (initially, of UK health professionals) might respond could be difficult. We approached this task from the outset as a partnership (namely KTSP-King's College Hospital [panel 1], Tropical Health and Education Trust [THET, panel 2], a1nd Somaliland Partnership), talking and listening to each other in Hargeisa and London, and so we were able to identify areas for which input from the UK could make a difference. We have set short-term targets for a long-term vision.
KTSP work in Somaliland
Early visits to Edna Adan Hospital
The Edna Adan Hospital was still a building site in 2000 during the initial fact-finding visit. However on March 9, 2002, patients were admitted and 1 week later the first KTSP team visit took place. Within hours of their arrival, the first caesarean section was undertaken. Repeated follow-up visits have monitored progress, assisted staff training, and helped to start treatment protocols and improve care. As a result, the hospital has become a referral teaching hospital for reproductive health for a wide geographic area in the Horn of Africa. The hospital recognises that the KTSP teams have been vital in improving its standards, service delivery, and reputation.
Amoud University, Borama Hospital, Hargeisa Group Hospital, and the Regional Health Board
The initial work in 2002 was a means for building mutual respect and trust, an essential platform on which to build bolder partnership plans. On subsequent visits, KTSP members met tutors from a new medical school, established as part of Amoud University in Borama, which had begun training medical students in 2000. KTSP has responded by sending lecturers to fill gaps and lend support to tutors since 2003, both at the university and at Borama Hospital. Owing to this early and sustained support, King's College Hospital and THET are regarded as founding organisations of the university. The first seven students will qualify in 2007.
In June, 2003, the Hargeisa Group Hospital, the main government hospital, also requested assistance. The hospital, built in 1953 for a population of 30 000, now serves a city of more than 700 000 people and the northwest region of Somaliland, and it is one of only three acute district hospitals serving the 3£5 million Somaliland population. The hospital is managed by the Regional Health Board, an independent committee designated by the Ministry of Health and Labour to have responsibility for both primary and secondary health care in Hargeisa and the northwest region of Somaliland.
KTSP's initial work at Hargeisa Group Hospital included refurbishment and reorganisation of the accident and emergency department alongside a 2-week emergency skills course. A 6-month prospective audit of the assessment of major trauma in the department was then undertaken.
The next major collaborative project aimed to pull together various partners in Hargeisa under a strengthened Regional Health Board to rebuild health capacity and help to provide accessible care to the community at the point of need, including free care for the poorest people. This task demanded a lot of funding, and in 2004, THET was awarded a 5-year grant from Comic Relief, a major UK grant-giving agency, to sponsor this work. Stakeholders include Hargeisa Group Hospital, Edna Adan Hospital, and primary health facilities and their communities, all under the remit of care of the Regional Health Board. The project includes four elements. 1) The provision of a revolving drug fund for Hargeisa Group Hospital, so that staff and patients no longer have to buy essential drugs on the unregulated open market. 2) Training for school teachers in basic health care and first aid, a programme that has gained attention from the Ministry of Education, who see it as a model for the country. 3) South-south training in Ethiopia, Kenya, and Tanzania alongside support from UK health professionals, enabling partners in Hargeisa to receive appropriate new skills to develop a health system relevant to their own context. 4) Community education so that health-care options are known, as care at government institutions improves.
Human resource development in Somaliland
The initial teaching and training at Edna Adan Hospital, Hargeisa Group Hospital, and Amoud University has been followed by wider strategic human resource development for Somaliland. KTSP is now more formally involved than previously in undergraduate and postgraduate teaching of medical and nursing colleagues and in development of a new national programme of training for health officers. In addition to these formal educational programmes, other groups receiving training, usually on the job, include managers, pharmacists, and physiotherapists (as part of the development of a national clubfoot programme). Currently, no courses are available to train new health professionals for support services, and the quality of these services is limited. However, although not part of our work, the Community Fund has sponsored a training course at Edna Adan Hospital for laboratory technicians and has upgraded the laboratory at Hargeisa Group Hospital and surrounding mother and child health centres.
Somaliland* Uganda UK*Somaliland is not recognised as a state by the United Nations; hence, the above statistics apply to the recognised Somali Republic (Somalia and Somaliland). Reproduced from The World Health Report 2005, by permission of the World Health Organization.
Life expectancy in 2003 (male/female) 43/45 47/50 76/81
Under-5 mortality in 2003 (probability of dying per 1000) 225 140 6
Maternal mortality per 100 000 live births in 2000 1100 880 11
Total health expenditure in 2001 (proportion [%] of gross
domestic product) 2.6 7.3 7.5
Proportion (%) of 1-year-olds immunised with three doses of
diphtheria, tetanus, 40 81 91
and pertussis in 2003
The Tropical Health and Education Trust (THET) supports health workers in developing countries to meet their own goals and the needs of their communities through skills training and development of institutional capacity. THET works in partnership with indigenous health professionals to improve care, building on existing systems and increasing access to health care for those who most need it, with major programmes in Ethiopia, Ghana, Malawi, Somaliland, and Uganda. THET responds to the requests of partners overseas and works with them to address needs they identify. In 2005, THET became the national umbrella organisation for NHS Links, partnerships between hospitals and teaching institutions in developing countries and their counterparts in the UK. Links are long-term partnerships for mutual benefit and are a proven means for establishing real global partnerships for development-Millennium Development Goal 8.
The challenge of medical education in Somaliland will be to ensure that students not only are equipped to practise a disciplined clinical method but also are confronted by and able to contribute to the pressing needs of the country's poor population. A second medical faculty has opened at Hargeisa University, and in March, 2005, representatives of THET, King's College Hospital, and the two universities held strategic discussions on the design of the curricula of the infant medical schools and the contribution that they could make to health care for the poorest people through students' community work. In Borama, the emphasis on community outreach is already being established, with all students taking responsibility for between two and four families in the village of Daraymacaane, which is located several kilometres outside the town.
The Institute of Health Sciences, a government institution, is now taking over responsibility for nursing training from Edna Adan Hospital since reopening in 2002. It aims eventually to provide basic and post-basic training for different cadres of health professional- nurses, laboratory technicians, microbiologists, radiography technicians, and midwives. The institute now has more than 120 student nurses enrolled but its resources are scarce and most of the tutors have not had refresher training for many years. KTSP is already helping with gap filling lectures at the institute, but the strategic direction will be in training of the teachers and ongoing support for the institute's staff .
In 2005, a new curriculum for health officer education was designed through KTSP collaboration and approved by the Ministry of Health and Labour. This new programme is based on experience in neighbouring Ethiopia, where health officers are at the frontline of rural health care. These workers provide an essential service in countries where doctors are scarce, without contributing to professional migration, since their qualifications are not exportable. With the first medical trainees at Amoud not due to qualify until July, 2007, an 18-month post-nursing health officer training course will augment Somaliland's resource of newly trained health professionals and could pave the way for their countrywide deployment.
What are the benefits?
No programme of this sort, which is active across many disciplines, should proceed without careful monitoring and evaluation. For all the activities, we have put into place methods to monitor what is done to ensure work is effective and targeted to needs. Assessment techniques have included end-of-course examinations and questionnaires and assessments by student participants, structured interviews by visiting assessors from THET, audits of physical and structural changes in Somaliland, and audits of functional changes within Somaliland institutions.
Figure 4: Edna Adan Hospital
The hospital was built on a plot of land obtained in 1997 in the poorest part of Hargeisa. The land, formerly used as an execution site and then as a rubbish tip, has been turned from a place of misery and death to a place of joy and new life.
Edna Adan Hospital is a non-profit charity. It was built by one of our team (EAI), who donated her UN pension and other personal assets to address the grave health issues that endanger the lives of women and children in Somaliland. It has provided much needed reproductive health care to meet the requirements of the expanding population of Hargeisa and the rest of Somaliland, and the hospital is run according to strict internationally accepted standards of maternal and child care.
In 2001, on the same site as the hospital and 6 months before it was opened, Edna Adan Hospital began training 30 nurses-they represented a new generation of health professionals for Somaliland and the first to be trained since 1988. Human resource development at the hospital, for which KTSP has provided support, has included 3-year general nurse training, post-basic midwifery training, 1-year training for laboratory technicians, in-service training for midwives, and training for traditional birth attendants.
To detail all the benefits derived from KTSP in Somaliland is not possible here, but table 2 highlights a representative selection.
The ultimate objective of this programme is to rebuild capacity in Somaliland. However, the reason that this link works so well is that it is a true partnership for reciprocal benefit - a fundamental principle for any partnership. Indeed, there has not been any opposition to or disinterest in it. UK health professionals from King's College Hospital visiting Somaliland witness team building and multi-professional working and development of problem-solving and leadership skills. This observation has led to an enhanced appreciation of colleagues' skills and a breakdown of conventional barriers between departments. Links can also be a method for recruitment and retention of staff . The visiting teams, working with colleagues in Somaliland who are faced daily with almost insurmountable challenges, return to the UK with a renewed perspective on their own work and greater appreciation of King's College Hospital. Patients have also benefited from the enhanced skills, experience, and knowledge gained in Somaliland, particularly in obstetrics and midwifery, with the advanced pathology encountered. Panel 4 summarises these benefits.
Legitimacy, migration, and sustainability
"Many rehabilitation interventions are implemented outside the state structures and therefore do not serve to strengthen these institutions in the longer term."4
Although KTSP started informally outside state links, through individual invitations to help at Edna Adan Hospital and later at Hargeisa Group Hospital, the ensuing partnerships with government institutions have been strengthened. The work of KTSP is ultimately accountable to the Ministry of Health and Labour, and one of our team (EAI) is currently Minister of Foreign Aff airs.
In a post-conflict society, the absence of any real capacity in the government forces early important development through the private sector and with community-initiated organisations. The institutions with which KTSP is working, when they are not government supported, are operating in the place where government institutions ought to be, and would be if the government capacity could be increased. Without exception, KTSP works with partners who serve a wide community in the interests of public service, rather than for profit. The work builds the capacity of existing institutions and organisations, using infrastructure, staff , and systems already present.
The legitimacy for NHS personnel in leaving their jobs for short trips to work in developing countries is another important consideration. When staff do so, within the context of an institutional link, they have the support of a growing consensus among senior figures in UK health care. Sir Nigel Crisp, the former Chief Executive Officer of the NHS, writes: "Links allow NHS staff to contribute to the improvement of healthcare worldwide, whilst continuing to serve their own communities. Links motivate staff , enlarge their experience, sharpen their skills, and thus help to retain them within each country's health service."5
In 2005, a UK-wide links movement-NHS Links- gained momentum and is bringing links issues to the attention of service managers and policymakers. All NHS trusts in the UK could have a link; those starting up can learn from already established partnerships through best-practice networks and published work. KTSP itself enjoys the strong local support of the NHS Trust board and, as a result, an international development unit is being established. This facility will give administrative, managerial, and fundraising support and will raise awareness about international health issues locally.
Links provide one response to the issue of health worker migration from developing countries to richer nations. Africa's share of the global disease burden is 25% whereas its share of the world's health workforce is 13%; 6 this dire situation is worsened as a result of health-worker migration, which has increased greatly in recent years.7 If staff are to be retained, positive measures are needed, and NHS Links aim to provide such support. Training can be the slow way to achieve results, but we are avoiding the snare of excessive focus on supply of drugs and equipment in isolation, which sometimes outstrips the capacity of the systems and human resources that should support them.4
The sustainability of all KTSP activities is threatened, however, by a gulf in resources that is far greater than the capacity of the link to address: incentives for all staff in Somaliland in the form of regular and realistic salaries are desperately needed. Programmes of training and support will ultimately fail unless these issues are addressed and staff will seek private incomes or introduce informal charges, with the long-term effect of such practices marginalising poor people.
These issues are not unique to Somaliland. A report for the UK Department for International Development of service delivery in countries emerging from conflict confirmed the vital role of the State, especially in the period surrounding peace, when to restore confidence in governing authorities is vital.4 During this time, budgetary support for salaries and training of staff in the health sector could be appropriate despite the risks associated with weak financial oversight.4
In Somaliland, KTSP has been asked to address such policy issues and will do so through support for the newly formed Somaliland Medical and Nursing Associations and by continued work with existing partners who have, through their initiative and vision, assumed responsibility for rebuilding the health system of a nation. However, without recognition and support from the international community, a realistic health budget is only a dream because the Somaliland government will not be able to provide realistic salaries for health workers.
Somaliland health professionals do not want to develop a culture of dependence on overseas aid, although the fact that major international agencies will need to have a crucial role is widely recognised. Education and training of all cadres of health staff are needed, and the story of KTSP activities from 2002 to 2005 show that successful partnerships are possible in a post-conflict nation.
Some of the lessons that we have learnt might be transferable to other post-conflict situations because of the standard on which our work is based. This principle has been a relationship of trust, built up over time, in which specific requests from the Somaliland team have required from the partners at King's College Hospital and THET a responsive, flexible, and innovative approach; there has been no prescription of what should be done. This strategy is applicable for rebuilding after any conflict and, indeed, underpins THET's long-term approach to health-systems development. Recognition of the mutual benefit of the partnership has resulted in a strong endorsement of the work-both within Somaliland and the UK-and a long-term commitment, which is essential because the needs are so great and the pace of rebuilding is not fast. Finally, because so many institutions were weakened or destroyed by the conflict, including strategic hospitals, professional associations, Regional Health Boards, educational institutions, and central government, the partnership has had to be active across a broad front. If it had been restricted in its aims, the major challenges mentioned in the introduction-the absence of central government finance, the lack of a health system, and few trained staff -could not have been addressed, and the development of a stable post-conflict society would have been impeded.
Panel 4: Benefi ts of KTSP for King's College Hospital
For individuals
* Multiprofessional working and learning
* Cross-cultural communication
* Enlargement of professional skills
* Developing leadership
For the institution
* Recruitment, retention, and training
* Valuing diversity and cultural change
* Much strengthened staff
* Giving back value and human resources
Somaliland, with so much progress against the odds, has been described as "Africa's best kept secret".8 Both the Somali and UK authors of this report would like to share the secret as we continue to work for the people of Somaliland.
Acknowledgments
We thank Abdirahman Ahmed Mohamed for his vital role in the early stages of KTSP and Prince Ade Ade-Odunlade for his important contribution to early visits. We also thank the donors who have made possible much of KTSP's work in Somaliland: Community Fund, the Association of Surgeons of Great Britain and Ireland, Comic Relief, the British Embassy in Addis Ababa, the King's Development Award, UNDP, and Zurich Financial Services Community Trust. The sponsors had no role in design of the work, data collection, data analysis, nor in the decision to submit the report.
References
1 WSP International. Rebuilding Somaliland issues and possibilities. Eritrea: Red Sea Press, 2005.
2 Hansen P. Migrant transfers as a development tool: the case of Somaliland. Copenhagen: DIIS, Migration-Development Workshop III, 2004.
3 Ahmed II. Remittances and their economic impact in post-war Somaliland. Disasters 2000; 24: 380-89.
4 Vaux T, Visman E. Service delivery in countries emerging from conflict: report for DFID. Bradford: University of Bradford, Centre for International Co-operation and Security (CICS), 2005.
5 Tropical Health and Education Trust. Links manual. London: THET International, 2005.
6 Commission for Africa. Our common interest: report of the Commission for Africa. London: Commission for Africa, 2005.
7 Mensah K, Mackintosh M, Henry L. The skills drain of health professionals from the developing world: a framework for policy formulation. London: Medact, 2005.
8 Jhazbay I. Somaliland: Africa's best kept secret. Umrabulo 2003; 18: 53-55. http://www.anc.org.za/ancdocs/pubs/umrabulo/ (accessed May 14, 2006).
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