Health Services for the drought-affected populations
in the Somali National Regional State (Gode, Denan and Jijiga)
INTRODUCTION
The Somali National Regional State is one of the poorest regions in Ethiopia. It has an
estimated population of 3.5 inhabitants who are predominately agro-pastoralists and
pastoralists. Refugees, internally displaced persons and drought-affected populations
constitute a large percentage of the region's population. Persistent migration of the
population is an important characteristic that renders any development planning for
the region very difficult. This is a region characterised by extreme poverty, low levels
of education, poor infrastructural facilities, lack of efficient institutional capacities,
logistical constraints and recurrent natural disasters such as famine, drought,
epidemics (both human and animal) and floods. Communication links with the rest of
the country are poorly developed thus making it an isolated region. Any development
or investment envisaged for the health sector is heavily influenced by the political,
social and economical factors prevailing in the region. However, there is an
opportunity that the on-going emergency response for the affected populations will
spark off a new momentum and be a magnet for a special focus from development
agencies to reform their regional plans. For the region to develop reliable systems for
preparedness and response, a special consideration must be given to appeal to a
sustained and long-term commitment by the international agencies, NGOs and the
central authorities. There are an estimated 200,000 refugees residing in the Region in
seven refugee camps along the border with North West Somalia (Somaliland).
TERMS OF REFERENCES
1. To assess the health situation of the drought-affected populations in the
Somali National Regional State, and to identify gaps in the health delivery
systems.
2. To look into the co-ordination mechanisms that are in place, and how best the
regional health authorities are managing to provide technical backstopping to
those working in the periphery.
3. To familiarise with the Horn of Africa Initiative for the Cross Border Control
of Communicable diseases, and how best this has impacted on the health
situation in the border areas.
4. To identify those conditions that hamper the effectiveness and equitable
distribution of relief supplies and promote the transmission of communicable
diseases.
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METHOD OF ASSESSMENT
The method of assessment employed consisted of direct interviews of the
beneficiaries, direct observation of the health facilities providing services, and
interviews with the services providers including UN agencies, NGOs and local health
authorities. Health reports and data at the hospitals, clinics and other health facilities
were also reviewed and studied. Individual meetings, group discussions and
participation in health co-ordination meetings were also utilized.
INTRODUCTION TO HEALTH SERVICES
Any health services for the drought-affected populations cannot be developed in
isolation and without giving due consideration to the health needs of the host
population. This implies that inputs intended for the drought-affected populations will
also serve meeting the needs of the host populations. The development of the health
care system should be entwined as an integral part of the overall development plan of
the region. Regional health plans should not be conceived in isolation, and the
formulation of appropriate health strategies should be built from the bottom up and
embedded with flexibility as dictated by local conditions and circumstances.
Emphasis must be given to the empowerment of the community and their ownership
of the health services promoted from the outset.
The health care system in the region is at crossroads. Poor planning and management,
years of neglect, shortages of qualified health planners and administrators and
inadequate financing, characterize it. It is critical that international agencies are
committed and ready to provide the thrust needed to effectively address the health
problems of the region and to aim at strengthening the local capacity. Quick fixes are
not the required answer for a variety of chronic problems faced by the region.
HEALTH INFORMATION SYSTEMS
At present the health information system in the Somali National Regional State is
imperfect or quasi non-existent. The situation of the health information system in the
region is appalling, and one should consider this as a priority in order that trends of
mortality, morbidity, and nutritional status should be closely monitored. It is essential
that data collection should be limited to that information that can and will be acted
upon. Information that is not immediately useful should not be collected during the
emergency phase of a relief operation. Overly detailed or complex reporting
requirements will result in non-compliance.
The most valuable data are generally simple to collect and to analyse. Standard case
definitions for the most common diseases of morbidity and mortality should be
developed and put in writing. This is an area whereby NGOs and UN agencies could
help the local regional health authorities and strengthen their capacities for developing
an effective health information system.
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Data collected from selective feeding centres constituted the main source of health
information of which NGOs and others base their decisions and evaluate the
effectiveness of their programmes. Comparatively health centres, clinics and hospitals
managed by the local authorities are unable to generate reliable data to supplement
that from the children centres. This dichotomy may provide a convincing explanation
the lack of funds for the overall health care services. A unified health information
system is a priority need.
An effective health information system should provide continuous information on the
health status of the drought-affected population and comprises both ongoing routine
surveillance and intermittent population-based sample surveys. This information is
useful for the following requirements:
 Follow trends in the health status of the community and establish healthcare priorities.
 Detect and respond to epidemics
 Evaluate programme effectiveness and service coverage
 Ensure that resources are targeted to the areas of greatest need
 Evaluate the quality care delivered.
Recommendation

A simple and reliable health information system should be composed and
implemented. This must include collection of data from all the facilities
(feeding centres, hospitals, health clinics etc.,), and to be collated and analysed
by a single centre. The local health authorities are better placed to carry out
this function. However, a tangible technical support is needed from the UN
agencies and NGOs to strengthen the capacity of the local health authorities to
properly establish that unified health information system. It is important that
information is shared, and that methods of data collection and analysis are
standardised.
MORTALITY AND MORBIDITY OF COMMUNICABLE DISEASES
Densely populated villages and towns with poor sanitation, inadequate clean water
supplies, and low-quality housing will contribute to the rapid spread of diseases in
these locations (e.g., Denan, Shinnille). In addition, the interaction between
malnutrition and infection in these populations, particularly among young children,
will also contribute to the high rates of morbidity and mortality from communicable
diseases. There are no as such community-based structures, which could enable the
early detection of communicable diseases and epidemics.
Measles, diarrhoeal diseases, acute respiratory infections (ARIs), tuberculosis and
malaria are the primary causes of morbidity and mortality among the displaced
populations in the Somali National Regional State. Epidemic-prone diseases such as
meningococcal meningitis, cholera, measles and bacillary dysentery are also wellknown health problems in the region. The obvious disproportionate representation of
international agencies in affected zones is a determining factor that forced displaced
populations to migrate en masse and end up in towns and villages (for example, Gode
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and Denan) characterised by overcrowding, poor sanitation, substandard housing, and
limited access to health care. These conditions hamper the effectiveness and equitable
distribution of relief supplies and promote the transmission of communicable
diseases. There are no as such community-based structures, which could enable the
early detection of communicable diseases and epidemics in the areas visited.
Mortality rates are the most specific indicators of the health status of emergencyaffected populations. However, the information on mortality in the region is very
scanty, and very few retrospective surveys carried out by MSF (H), ICRC and SCF, in
collaboration with UNICEF, have shown mortality rates ranging from 8.9/10,000/day
to 3.2/10,000/day in the general population. Another survey carried out by MSF in
May in Denan has shown an alarming rate of 27.5/10,000/day among under-fives.
Among the many problems encountered in estimating mortality under emergency
conditions are the recall bias in surveys, families' failure to report prenatal deaths,
inaccurate documentation (overall population size, births, age-specific populations),
and lack of standard reporting procedures. In general, bias tends to underestimate
mortality rates, since deaths are usually underreported or undercounted, and
population size is often exaggerated. However, the limited surveys conducted by
NGOs and UN agencies show a trend that indicate communicable diseases
significantly contribute to these high rates of morbidity and mortality.
Recommendation

Efforts should be aimed at reducing the incidence of communicable diseases.
This will primarily focus on the provision of adequate quantities of clean
water, improvements in sanitation and the establishment of appropriate health
services. Dissemination of best practices and proven prevention and control
strategies should be advocated.

Health care services should target the leading causes of morbidity and
mortality. The prioritisation of health needs will enable health authorities the
better utilization of available resources and the development of a health care
system that is appropriate and affordable. Ensuring that emergency
interventions are enhancing and strengthening the long-term national health
goals is a requirement.
CONTROL OF TUBERCULOSIS
Tuberculosis is a major public health in the Somali National Regional State. The
annual risk of infection (ARI) in this region is estimated at 3-5 - 5% and TB is one of
the leading causes of both hospital admissions and deaths according to the scant data
available in the major hospitals in the region. The incidence rate for smear positive
cases is considered to be between 175 - 250 /100,000 population in the region. This is
a relatively high incidence.
Because of the limited resources available, efforts to control transmission of TB
within an emergency should focus on the primary sources of infection, i.e., those
patients for whom microscopic analysis of sputum smears demonstrates the presence
of Acid-fast Bacilli (AFB). From the outset of an emergency, the TB control
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programme should establish a standard policy covering areas of case definition, case
finding, treatment protocol, and the supervision of chemotherapy. This policy should
be devised by the local authorities and adhered to by all organisations and agencies
providing health services to the affected population. In Gode, the TB control
programme is not working effectively in the main hospital, and the involvement of the
agencies is very minimal. It is an area that needs further additional resources in order
to strengthen the programme.
The selection of a first-line chemotherapy regimen should generally be consistent
with the national policy set forth by the Ministry of Health. The strategy to employ a
short-course therapy is the right policy to address the abnormally high rate of
transmission observed in overcrowded conditions of the affected population. The
constraints faced by the region comprise mainly of management problems, shortages
of essential drugs, lack of laboratory facilities and non-compliance with control
policies.
MSF (B) is supporting an effective TB pilot project in the Jijiga Zone and plans are
underway to further extend the programme to other zones. The impact of the project is
encouraging with nearly 80% cure rates for both new and re-treatment cases and less
than 10% of the cases listed as defaulters for 1998. The problem with the programme
is one of sustainability as it has been developed independently in its first phase with
less integration to the overall health programme. One would like to see that the local
health authorities assume a full responsibility of the implementation of the
programme with technical support and backstopping from the MSF (B).
Recommendations




The success of the MSF (B) project can be replicated in other areas. However,
further support and additional inputs from other agencies and the national
tuberculosis programme (NTP) are highly recommended.
There is an urgent need to closely associate the project with the regional health
authorities. It is imperative that the regional health authorities are actively
engaged in the implementation of the project, and ensure that it is being fully
integrated into the regional health plan.
The World Health Organisation (WHO) should associate itself with the
programme, and ensure providing technical and material support as needed. It
must use its leverage with the regional health authorities that the TB
programme is an integral component of the overall health care.
Within the strategies of the Horn of Africa Initiative, the programme should
develop carefully planned linkages with the TB programme in North West
Somalia. This will imply standardisation of treatment regimens, referral
systems and common tracing procedures for defaulters.
ROLL BACK MALARIA
Malaria is one of the leading causes of morbidity and mortality in the region. Its
prevalence varies from area to area with seasonal fluctuations. This is a disease with
major public health significance, and its current prevention and control strategies in
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the region need to be strengthened. Knowledge of the epidemiology of transmission,
including local vectors, is essential to a malaria control effort. Preparedness for
possible outbreaks of malaria during the coming season is essential. Immediate inputs
are needed for the standardisation of treatment protocols, provision of technical
support to the regional authorities, supply of essential drugs and strengthening the
laboratory services.
Recommendation

The prevention and control of malaria in the region should be considered as a
health priority. International agencies (UN and NGOs) should provide the
needed support to the regional and zonal health authorities as deemed
necessary. The control of the disease should be multifaceted and
comprehensive including the introduction of appropriate vector control
techniques.
HIV/AID/STI
HIV spreads fastest in conditions of poverty, powerlessness and social upheavalsconditions that are prevalent in the Somali National Regional State, and further
exacerbated by the effects of the drought. A massive migration of drought-affected
populations from rural areas into the heavily populated areas in the outskirts of towns
(e.g., Gode) has occurred. This phenomenon of population movement could facilitate
a dramatic increase of the risk of infection, as the drought-affected people with rural
background are less aware of the means of prevention.
Recommendation

This is an area that needs an immediate attention. There are no programmes to
combat the spread of HIV/AIDS in the region, and a very little is known on its
magnitude. However, there are obvious signs, which point to that the problem
of HIV/AIDS in the region is serious. The regional health authorities should
treat this issue as a major public health problem, and seek technical support
from specialised agencies such as UNAIDS, WHO and the National AIDS
Programme (NAP).
SELECTIVE FEEDING PROGRAMMES.
The current humanitarian intervention strategy is primarily food-driven, and
constitutes mainly of general food distribution and selective feeding programmes.
There is a very limited input in the overall health care services, and in other vital
sectors such as water, sanitation, livestock, agriculture and shelter. However, one
should underline that the response of the international community has been very
effective in accessible areas, and have certainly averted unnecessary deaths. The task
now is to develop sustainable programmes that will remain viable over a number of
years with diminishing human and material resources from outside sources.
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Recent nutrition surveys suggest that the previously documented high malnutrition
rates are in the decline, and improvements of the nutritional status of the children
have been detected in many of the operational areas. However, the present rates are
still high, and remain in the territories of concern.
The prevalence of acute malnutrition acts as an indicator of the adequacy of the relief
ration. A high prevalence of malnutrition in the presence of an adequate daily ration
may indicate inequities in the food distribution system, or high incidence rates of
communicable diseases (e.g., measles and diarrhoea). There are indications that
suggest both these factors exist in the region whereby the overall health care system is
very weak, and that the distribution of food in certain villages and locations of the
region requires close attention and monitoring. It is important to recognize that
comparatively WFP and UNICEF are doing an exemplary job with all the apparent
difficulties that exist in the region.
This is an indication that the situation is still fragile, and a full recovery of the
population from the drought consequences will take time and a concerted effort to
broaden the response in other vital sectors is warranted.
Recommendation

There is a need to develop a phased exit strategy of the food aid programme
and a corresponding increase of inputs in other vital sectors such as health,
water and sanitation, livestock and agricultural programmes. The exit strategy
should be based on coverage, impact indicators and food security in the
region.
THE ROLE OF NGOs
The role played by NGOs in the emergency response including all vital sectors has
been substantial. They are widely represented in the field and they constitute the
frontline relief workers. The systematic inclusion of NGOs in the decision-making
process for the emergency as key partners is fundamental. Equally important is the
role of WHO as a bridge between NGOs and the Ministry of Health (MOH). We need
to promote a unified approach encompassing all potential players, and one that
ensures complementarity, pooling of resources and joint planning. NGOs constitute a
powerful group to reckon with, and their prominent position necessitates that they are
indispensable for any humanitarian response. WHO should play a proactive role to
bridge the gap that currently exists between the MOH and NGOs?
The disproportionate representation of international and local relief organisations
in certain locations (e.g., Gode) may have resulted in the apparent en masse migration
of displaced populations into these towns and villages. Also it is true that the response
of the international agencies (UN and NGOs) to the impact of the displaced
populations is varied and characterized by different approaches and capabilities.
Standardization of procedures and sound policies for health interventions is essential
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and should be streamlined. This is an area whereby WHO could play a leading role,
and facilitate along with the MOH an effective co-ordination among all actors.
Recommendation

WHO should look into the possibility of designating someone to become the
focal point for NGOs? This function will undoubtedly enhance a close
cooperation and collaboration between WHO, NGOs and MOH and will
facilitate forming a strong partnership among the parties. Soliciting an alliance
with NGOs will strength the leading role of WHO in the health sector.
COORDINATION, CAPACITY BUILDING AND HEALTH FACILITIES
Setting up an effective co-ordination mechanism of the health services by the regional
health authorities at Jijiga level is still to take shape. There are obvious deficiencies
within the existing regional structures. The lack of effective co-ordination
mechanisms has resulted in the application of different standards and health policies
by key health agencies. The limited presence in the field by UN specialized agencies
in the health sector is unfortunate. The need to capacitate the local health institutions
with the provision of technical support is essential, and this should be addressed
carefully and intelligently.
The overall coordination among the UN agencies and NGOs operating in Gode Zone
is very good with structured forums of communication, information sharing, standard
settings and the development of shared objectives. However, the local government
entity is very weak and need to be strengthened. It is crucial that outside resources,
including central health authorities, complement and support the local initiatives and
realities and are not devised as parallel systems to substitute the local response.
Outside assistance should always enhance rather than hinder the development of local
capacity and attempts to foster self-sufficiency among the affected populations.
The high salaries offered by international agencies have encouraged key health staff
to leave local clinics and hospitals and seek employment in the selective feeding
centres. This example reveals how the desire to save lives in the short term may have
a long lasting detrimental effect on the health of the region.
The health infrastructures along the border areas are very weak, understaffed and
poorly managed. Absence of qualified personnel in health management,
administration and health planning has been evident. The situation has also been
complicated by the presence of a diversity of NGOs who depend on recruiting
qualified staff with high salaries, thus creating a vacuum in the government
institutions. Limited resources and logistics support, shortage of critical health
manpower worsen the situation and limit the impact of the health care delivery
systems on the health status of the displaced populations. In general the health
facilities in the whole region are not fully utilized.
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Recommendations:

A sustained commitment of technical support to the regional health authorities
by UN agencies and the central Ministry of Health (MOH) is imperative. This
could be provided in the form of seconding health planners and public health
experts on communicable diseases to the region for a substantial period of
time, approximately up to two years. The involvement of the specialized
health agencies is a pre-requisite to initiate the attainment of effective
institutional capacity in the long-term.

Structured lines of communication and the establishment of an effective
networking between political entities (DPPC, DPPB and DPPD) and the health
authorities at central and regional levels should be devised. At present the
interaction between DPPC and MOH is very weak. There should not be any
duplication of functions, roles and responsibilities between these institutions
and the need to introduce an organizational system that guarantees checks and
balances is urgent.

The regional health authorities should play the lead role to effectively coordinate the response and maximise impact in the region. There is a room for
the Office of the Coordination of Humanitarian Affairs (OCHA) to assist the
government in co-ordination modalities and effective mechanisms that could
be utilized to bridge the existing gap among governmental entities.

The provision of sustained training of the nationals and the introduction of
evidence-based interventions are key requirements for any success. The
training programme should focus on the priority health needs of the region
including the following issues:


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Development of a simple and effective health information system.
Standardisation of case management in all zones.
Capacity building geared towards health management,
administration, planning and co-ordination requirements.
Prioritisation of health needs based on well-defined indicators.

Further expansion of the health facilities coverage should only be undertaken with
a very strong justification based on a quantified need. This will mean that there
should be a moratorium on new constructions of hospitals, health centres and
other infrastructural facilities in the whole region. We need to address the health
development of the region within the context of available resources and the
absorptive capacity of the local institutions. All efforts should be geared towards
making existing facilities to be fully utilized and properly functioning. It is easier
to build a health facility but to make it fully operational is a daunting task.

An important area that needs to be strengthened, equipped and properly staffed is
the laboratory service. This area should specifically targeted, developed
strategically taking the realties on the ground.
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EARLY WARNING SYSTEMS AND PREPAREDNESS
At present the region is not prepared for any disaster or emergency. Preparedness for
sudden population displacement is critical and should be targeted at the most
important public health programmes identified in previous emergencies: malnutrition,
measles, diarrhoeal diseases, malaria, ARI, and other communicable diseases (e.g.,
meningitis) that result in high death rates. Preparedness requires that planning for
emergencies be included as an integral part of routine health development
programmes in countries where sudden displacements might occur. These
programmes include:
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Effective health information system
Diarrhoeal disease control programmes
Expanded Programmes on Immunisation (EPI)
Control Programme for endemic communicable diseases
Nutrition programmes
Continuing Education Programmes for health Workers.
National public health programmes should include detailed contingency planning for
sudden emergencies and population movements, both internally and from
neighbouring countries. This was not the case for the regional health authorities in the
Somali National Regional State, and the region was not prepared for the emergency.
No allocation of resources was made within the regional budget for the fiscal year of
1999 - 2000.
OTHER VITAL SECTORS (Water, Sanitation etc.,)
An adequate water supply and an appropriate sanitation programme are crucial
components of attempts to prevent disease and protect health and, as such, should be
among the highest priorities for relief workers and the local authorities in the region.
Urgent inputs are needed particularly for the water, sanitation, livestock and
agriculture.
The emergency situation is not yet over and a full recovery of the population from the
drought consequences will take longer. This implies that a concerted effort is needed
to broaden the response in other vital sectors rather than food aid. It is time that those
developmental agencies such as WHO, UNDP, FAO and others should step in, and
consolidate the gains of the emergency response with the application and
implementation of best practices. This must include the provision of appropriate
training of the local authorities and enhancing institutional capacities for setting up
sustainable systems
CONCLUSIONS.
The response of the international community and the Government of Ethiopia has
been very effective. Surely it has averted unnecessary deaths that may have otherwise
would have occurred. However, the overall health situation of the drought-affected
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populations is far from being staple. The potential for outbreaks is still imminent and
communicable diseases such as diarrhoeal diseases, acute respiratory infections and
dysentery remain the leading causes of morbidity and mortality. This is also
compounded by the weak capacity of the regional and zonal health authorities. The
emergency response is not yet complete, as the health situation of the targeted
population still remains very critical and fragile.
ACKNOWLEDGEMENT
The author will like to express his appreciation to the regional health authorities for
their unlimited support, and their willingness to share their constraints, weaknesses
and strengths with transparency. Also is important to extend thanks to the Emergency
Unit Co-ordinator, UNICEF and WFP teams in Gode town who unreservedly offered
unequivocal support during the mission. Finally my sincere appreciation goes to the
drought-affected populations in Gode, Denan and Shinnile who diligently and
uncomplainingly coped with so many surveys and assessment missions by outsiders
asking the same questions all the time.
Mohamed W. Dualeh MD MPH
WHO Special Public Health Adviser for OCHA
Ethiopia/Addis Ababa.
3 - 12 September 2000
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