COVID-19 has shown the fault lines in healthcare systems around the world, particularly in fragile states where access to public health services has been disrupted or is extremely limited. In Somalia – which has experienced decades of conflict and political instability since the collapse of the state in 1991 – the lack of a robust health system has impacted the country’s ability to deal with the pandemic.
Amnesty International found that only one hospital in the entire country – the De Martino hospital in Mogadishu – handled COVID-19 patients at the start of the pandemic. And even those who were treated there had to contend with several challenges, including lack of oxygen and ventilators. A doctor at the hospital said he had to use a single nasal cannula for multiple COVID-19 patients. He witnessed four elderly patients who needed oxygen die within minutes of their arrival at the facility. “I can still remember their faces,” he recalled.
As of the end of August, there were 17,466 confirmed COVID-19 cases and 977 deaths in Somalia since the start of the pandemic. However, these figures are likely to be underestimates due to insufficient testing and official under-reporting, which makes it difficult to assess the full impact of the pandemic in the country. Most ministries and government departments are under-funded and not fully operational, which makes monitoring and reporting problematic.
Vaccine hesitancy is another challenge. So far, only 297,107 COVID-19 vaccines – slightly less than half of the total number of vaccines donated to Somalia by COVAX and China – have been administered, partly due to widespread vaccine hesitancy and misinformation, including among healthcare workers. Nineteen of the 33 healthcare workers interviewed by Amnesty International said that they had opted not to take the vaccine for a variety of reasons, including a belief that the vaccine causes infertility.
Overstretched health facilities
Poorly equipped and under-staffed hospitals and clinics across Somalia are affecting the country’s ability to handle not just COVID-19 patients, but people suffering from other diseases as well. There is only one qualified surgeon per 1 million people in the whole country, and only 46 ICU beds and 15 ventilators.
In 2016, there were just 799 operational health facilities for a total population of nearly 16 million, or 1 facility per 20,000 people. Most of these facilities tend to be concentrated in urban areas; only 15% of rural populations have access to healthcare. It is estimated that up to 90% of Somalia’s population relies on private facilities, which are generally poorly equipped and largely unregulated. When COVID-19 struck Somalia, private healthcare facilities had to provide services such as testing and quarantining.
In regions experiencing conflict, militias have targeted healthcare facilities, with facilities in Al Shabaab-controlled areas at particular risk. Insecurity in remote rural areas and in some conflict-prone regions make it difficult for people to access hospitals. And most of these hospitals were already suffering from lack of sufficient trained personnel before the pandemic hit. A May 2020 study found that healthcare facilities are ill-equipped to meet even the most basic primary healthcare needs, and that there is a huge scarcity in all categories of healthcare professionals. In 2014, there were only 9,566 healthcare professionals in the country, including doctors, nurses, and midwives, according to a WHO assessment. That’s a ratio of 0.34 medical workers per 1,000 people.
Women and children have suffered the most during the pandemic. Somalia has among the highest child and maternal mortality rates in the world. There are 829 maternal deaths per 100,000 live births in the country, and one in eight Somali children die before their fifth birthday. Life expectancy, at 55.7 years, is among the lowest in the region.
Budgetary constraints and poor governance
Budgetary constraints are limiting the Somali government’s response. Years of political instability, poor governance, and the ever-present threat of Al Shabaab have profoundly impacted the Somali government’s ability to raise sufficient revenue to deliver services. Although a federal government system has been in place since 2012, successive central and federal governments have been unable to unite Somalia’s deeply fragmented clan-based society, to make the country self-reliant, and to remove the threat of Al Shabaab, which has carried out frequent attacks in the capital Mogadishu.
The government’s budget is heavily dependent on multilateral and bilateral donors; only 38% of the funds in the $671 million budget for this year are expected to be raised through domestic taxes and international trade. More than 30% of this budget has been allocated to security, with health and health-related projects receiving just 2%. Officials say there are plans to increase annual budgetary allocations to the health sector to at least 5%, but this still falls short of the 2001 Abuja Declaration’s minimum requirement of 15%.
Corruption has also hampered Somalia’s efforts to rebuild public institutions. In 2020, Transparency International ranked Somalia as the second most corrupt country in the world after South Sudan. Politicians siphoning public funds for personal use is a potential reason why essential public services remain out of reach for the majority of the population, which is forced to rely on the private sector or charities to obtain these services.
International financial institutions are now lending a hand to improve governance and strengthen public healthcare systems in Somalia. In June, the health ministry announced the approval of a $100 million World-Bank-funded project aimed at improving health and nutrition services. The project will also build government capacity to produce regular and reliable health data.
With greater transparency and accountability within the federal government, improved security, increased revenue collection, and steady bilateral and multilateral support to the health sector, Somalia might just overcome some of the major challenges facing its healthcare system.
For more on the health, economic, and social impacts of COVID-19 in Africa, check out ONE’s Africa COVID-19 Tracker. It pulls together the latest real-time data from global institutions, governments, and universities about the impacts of the pandemic for the continent and for every African country – including information on food security. For more insights and analysis, sign up for our Aftershocks newsletter and follow us @ONEAftershocks.
Rasna Warah is a Kenyan writer and journalist who is working with the ONE Campaign’s COVID-19 Aftershocks project.