The year 2021 was a year of regaining confidence and showing our resilience to deliver results in the face of demanding and testing circumstances. Building on what we achieved in 2020, our work in 2021 supported Somalia to recover from the acute phase and the adverse impact of COVID-19 on essential health services and establish a strong health system beyond COVID-19.
Our work reflected in this photo album showcases how we are learning from the past and keeping our eye on the future to “beat back” COVID-19 and rebuild a health system that is more resilient and equitable.
Improving health service delivery using multi-year financing from the European Union aimed at building a resilient health system
In February 2021, the World Health Organization (WHO) officially launched a multi-year project to support the Federal Government of Somalia to prevent the community spread of the coronavirus disease (COVID-19) and strengthen the health services delivery across the country as soon as Somalia’s health systems start recovering from the aftershock of the pandemic. Funded by the European Union (EU), this multi-year project’s main focus is to build a strong district health system through strengthening essential public health functions at the community level. The project will support establishing integrated disease surveillance systems and improve the capacity of front-line health workers on disease detection and surveillance so that all public health threats can be detected in real-time and be contained at the source. In addition, the project will aim to improve the operational capacity of the district health system for delivering people-centred essential health services and ensure expanded access and availability of quality health care for the marginalized and vulnerable populations like the women and children through community health workers.
Establishing emergency, critical and operative care services in a fragile setting while capitalizing on the COVID-19 response
During the first quarter of 2021, the World Health Organization (WHO) country office conducted a series of activities aiming at building emergency, critical and operative care services as part of developing integrated service delivery for COVID-19 and other severe emergency health conditions.
Funded by the Pandemic Emergency Financing Facility of the World Bank, the activities followed a rapid assessment of critical care services conducted in 136 hospitals in all 18 regions using on-line tools which led to understanding the critical gaps in critical care services as part of the continuum of care for integrated service delivery. After the assessment, a series of activities led to establishing Basic Emergency Care at the health facilities which improved access of Somalis to good quality emergency and critical care services. The outcomes of these activities will help build sustainable emergency care services for all medical and surgical conditions in the country and integrate them into primary and secondary levels of care, while advancing towards universal health coverage (UHC).
On 9 December 2021, the World Health Organization (WHO) country office for Somalia officially launched a report on these activities entitled ‘Capitalizing on the COVID-19 response: towards establishing emergency, critical and operative care services in a fragile setting‘ which is available on line
Country Cooperation Strategy 2021–2025 launched with a vision for rebuilding health systems post COVID-19 ensuring health for all, by all
On the eve of Universal Health Coverage Day, the World Health Organization (WHO) country office for Somalia launched its five-year Country Cooperation Strategy (CCS), 2021–2025, for Somalia, which will guide its health programme over the next five years in line with national development priorities. On 11 December 2021 at Mogadishu, Dr Mamunur Rahman Malik, WHO Representative to Somalia and Head of Mission, was joined by HE Dr Fawziya Abikar Nur, Minister of Health and Human Services of the Federal Government of Somalia, and Mr Adam Abdelmoula, Deputy Special Representative of the Secretary General (DSRSG) and United Nations Resident and Humanitarian Coordinator for Somalia to co-sign the WHO CCS.
The Ambassadors of Italy and the United Kingdom, and other Heads of Mission and senior officials from the European Union Delegation and United States of America and were amongst the dignitaries who attended this event. Senior representatives and heads of United Nations agencies in Somalia, including the Food and Agricultural Organization (FAO), International Organization for Migration (IOM), United Nations Children’s Fund (UNICEF), United Nations Development Programme (UNDP), United Nations High Commissioner for Refugees (UNHCR), United Nations Office for the Coordination of Humanitarian Affairs (UNOCHA) and United Nations Office on Drugs and Crime (UNODC) also attended the ceremony.
Mitigating the effect of COVID-19 pandemic on TB, Malaria and HIV/AIDS control while keeping the progress on track
Though COVID-19 disrupted the essential health care services in Somalia which is likely to adversely impacting the progress made in the control of Tuberculosis, Malaria and HIV/AIDS over the years, WHO intensified its control and elimination activities aimed at mitigating the impact and keeping the progress on track. While case detection and notification for both drug-sensitive and drug-resistant TB increased by 2 and 18% respectively, expanded access to diagnosis using the GeneXpert and care for TB patients also improved significantly.
Test- and- treat for HIV/AIDS patients also improved considerably . A total 481 (61.2%) people living with HIV/AIDS were successfully enrolled on the antiretroviral treatment (ART) programme in 2021, thereby increasing the ART coverage to 44.7% of the estimated PLWHs in the country. In addition, the proportion of patients on ART, receiving the more effective dolutegravir-based ART regimens also increased from 39.7 to 76.0% in 2021, despite the constraint of low coverage of contraceptive services for women of reproductive age.
The malaria case management and vector control services were also scaled up as part of integrated primary health care services in the marginalized communities. Sustained reduction in number of reported malaria cases were also noticed due to effective scaling up of these services and improving case management. The total malaria cases reduced from 40,470 in 2019, to 29,439 in 2020 and 12,967 in 2021. The annual malaria parasite incidence also reduced from 2.8 per 1000 population in 2019, to 2.0 in 2020 and 0.8 in 2021. This has put the Somali National Malaria Control Programme on track to attain the national malaria strategic plan 2021-2025 targets. In 2021, malaria elimination activities also began in 6 districts (4 in Somaliland and 2 in Puntland) out of the 15 districts targeted for elimination as per the national malaria strategic plan (NPSP) of 2021-2025.
Ending the neglect of tropical diseases: improved case detection and mass drug administration continue to be key
In line with the national action plan for control and elimination of NTDs in Somalia, WHO continued its support throughout 2021 to the federal and state health authority to end the NTDs. As a result of these intensified efforts, the number of leprosy patients detected and treated increased from 107 in 2015 to 2638 in 2020 and 2030 in 2021, despite a global drop in cases reported and detected in 2020 due to the spread of the coronavirus disease 2019 (COVID-19). While training of healthcare workers continued to improve case detection and treatment of cases of visceral leishmaniasis, mass drug administration for schistosomiasis and soil-transmitted helminth infections were conducted in four endemic regions in the country. With funding support from Expanded Special Project for Elimination of Neglected Tropical Diseases (ESPEN) and END Fund, WHO intends to achieve more than 75% treatment coverage for school-age children to eliminate schistosomiasis as a public health problem by 2025 and deworming coverage for at-least 75% of eligible school-aged children and pre-school children by 2026 to eliminate soil-transmitted helminth infections.
Establishing a trauma care programme to manage high burden of injury
The disability burden of injuries in Somalia, measured in terms of disability-adjusted life year (DALY), continues to increase with the recent figure of 2019 showing that estimated 8.6% of disease burden in the country is attributed to injuries, an increase from 6.23% in 2000, owing to substantial increase in conflict, terror and road traffic accidents observed between 2000 and 2019. In order to include injuries as part of integrated care in the health facilities, the WHO country office for Somalia, with support from the WHO Regional Office for the Eastern Mediterranean, has set up a trauma care programme that is built on the vision of a holistic approach to trauma, from the point of injury, when one is injured, through surgery to the physical rehabilitation of the patient, back into the community. As part of this initiative, the WHO delivered the first Surgical Team Approach to Trauma (STAT) course, using high-technology surgical simulation facilities and virtual reality. Overall, 31 health workers were trained, bringing together surgeons and anaesthetists to embed a team-based approach to trauma management. The trainees were exposed to high-fidelity scenarios in an operating theatre, all while observing strict COVID-19 protocols and minimizing the spread of infection. They also learnt how to use ultrasound at the point of care and in emergency departments. Trainees were able to watch live how a trauma teams works in other contexts, including the UK.
The initiative was a stark reminder that a long-term problem necessitates a long-term solution, and that humanitarian and development efforts must be aligned to build a trauma care system that not only responds to today’s humanitarian needs but also developing a system that will serve the future needs of Somalia to reduce the high burden of injuries as a public health problem in the country.
Responding to COVID-19: sustaining the progress and expanding to improve public health functions at the frontline
WHO continued to support the national and sub-national health authorities to strengthen COVID-19 response activities and limit its transmission. While WHO worked on many fronts, the key to its successful strategy to slowing down the transmission was deployment of over 3300 community health workers who worked as “contact tracer” and “case detector” at the community level and were tasked with detecting cases and tracing close contacts. This vital health workforce was responsible for timely detection of 40% of all cases reported by the country by the end of December 2021. WHO’s work also contributed to improving access to high-grade medical oxygen by distributing oxygen concentrators at the 98 COVID-19 treatment centers supported by WHO and also through establishing solar-powered medical oxygen system. WHO also deployed a district-level rapid response team in each of the 118 operational districts for surveillance, field investigation and containment of community clusters as well as sample collection and distribution. WHO also improved access to testing by deploying antigen-based rapid diagnostic tests in the most remote, peripheral and hard-to-reach locations. This support has been a game changer for COVID-19 testing, detection and response in the country. Supported by the Foundation for Innovative New Diagnostics (FIND) for the rollout of the Ag-RDT in Somalia, these contributed to considerable improvement in access to COVID-19 testing and data showed that introduction of Ag-RDT has contributed to the detection of one fifth (i.e. 20%) of all confirmed COVID-19 cases across the country by December 2021 signifying considerable improvement in detection of cases and response.
FETP-Frontline training programme rolls out to build disease detectives and prevent spread of diseases
Having a public health workforce that is able to rapidly detect and respond to disease outbreaks is key for any health system, as recently shown on a worldwide scale with the current COVID-19 pandemic.
To address Somalia’s limited capacity in disease surveillance and response, the Somalia National Institute of Health (NIH) of the Federal Ministry of Health and Human Services organized the first training course of the Frontline-Field Epidemiology Training Programme (FETP-Frontline) in the country in October 2021. The FETP-Frontline is a 3-month on-the-job training programme supported by Africa Field Epidemiology Network (AFENET), the United States Centers for Disease Control and Prevention (US CDC) and the World Health Organization (WHO) and the Public Health Agency of Sweden. This training programme addresses the critical skills needed to conduct surveillance and response activities effectively at the local level, focusing on improving disease detection, reporting and response. It aims to improve field epidemiology knowledge, skills and competencies of trainees, and blends mentorship with classroom training and practical experiences to develop the public health workforce of a country. The trainees spend up to 12 days in 3 workshops and the remaining 8–10 weeks back at their jobs, where they conduct field projects to practice, implement and reinforce what they have learned.
Keeping Somalia polio free: delivering on the promise to protect every Somali child from polio using innovative approach
Since 2015, the country remained free from polio virus. However, outbreaks of other strains of poliovirus still pose a threat to unvaccinated children in a country where one in every seven children miss out routine immunization against polio and other vaccines-preventable diseases. While efforts continued to keep the country free from wild poliovirus, outbreaks caused by a rare strain polio virus called the circulating vaccine-derived poliovirus (cVDPV) continued to make the Somali children physically disabled and paralyzed. Owing to sustained and agile efforts, in March 2021, after 28 months, WHO declared the end of the outbreak caused by a rare strain of circulating poliovirus type 3 (cVDPV3) after the outbreak was successfully contained. Another type of outbreak caused by circulating poliovirus type 2 (cVDPV2), detected for the first time in Somalia in the environment in November 2017 and in a child on 11 May 2018, continues to threaten under-vaccinated children. So far, 23 children have been infected, with the last reported case detected in October 2021.
In September 2021, WHO country office, with support from its partners, introduced fractional-dose inactivated polio vaccines (fIPV) in 5 districts, reaching a total of 80 916 children under the age of 5. This pilot project was another innovative milestone for the country, particularly as a fraction of this vaccine offers a specific kind of immunity that is similar to one full dose of inactivated polio vaccine (IPV) in children previously immunized with oral polio vaccine (OPV). The use of fIPV is critical in responding to the current outbreak. In 2021, WHO supported conducting one National Immunization Day for polio campaign in July and two rounds of sub-national immunization days (sNIDs) in Somaliland during February and March 2021 for case response to an outbreak. During these campaigns, over 5 million under 5 children were vaccinated against polio reaching a coverage of 98.9%.
Making progress in establishing seasonal influenza surveillance to protect vulnerable communities from future pandemics
Somalia was one of the few countries in WHO Eastern Mediterranean Region without a functioning surveillance system for seasonal influenza. During the COVID-19 pandemic, WHO helped the Government of Somalia establish 3 molecular laboratories with biosafety level 2, which are capable of testing COVID-19 using rt-PCR assay. Building on this investment in enhancing country’s capacity for detection of COVID-19, WHO has supported the Federal Government of Somalia and Federal Member States expand the existing system of epidemiological and virological surveillance for COVID-19 to include sentinel-based surveillance system for severe acute respiratory infection and influenza-like-illness. In addition, WHO also equipped the 3 public health laboratories across the country in Mogadishu, Hargeisa and Garowe with necessary equipment and provided laboratory supplies for molecular detection of seasonal influenza. Owing to these efforts, Somalia became the 21 st country in the WHO Eastern Mediterranean Region and one of the 124 member states to participate in the WHO’s Global Influenza Surveillance and Response System (GISRS) which is a network of institutions across 124 countries conducting global influenza surveillance since 1952.
Rolling out COVID-19 vaccines: protecting Somalis from COVID-19 while creating a fairer, more equitable world
One year after the first case of COVID-19 was confirmed in Somalia on 15 March 2021, Somalia received the first consignment of COVID-19 vaccines- 300 000 doses of AstraZeneca vaccines (ChAdOx1 nCoV-19) through the COVAX Facility. The first dose of COVID-19 vaccine was administered in the country on 16 March 2021. The WHO country office supported the rollout of COVID-19 vaccines in the country, along with the United Nations Children’s Fund (UNICEF), turning the vaccines into vaccinated, through providing technical support for development of national vaccine deployment plan, microplanning for vaccines management, delivery and deployment and administration of vaccines and directly supporting the operations cost for vaccine administration. Despite issues with the unpredictable vaccines supply forecast and allocation which hampered the country in reaching to an optimal uptake, the country raced against time and was able to administer 85% of 2.5 million doses of COVID-19 vaccines received in 2021 from COVAX facility and other bilateral donations from France, Germany and the United States of America (USA). By end of December 2021, the country was able to fully vaccinate 6% of its population using a mix of routine and accelerated outreach and fixed centre-based immunization services. During one of the accelerated campaigns conducted during the last quarter of 2021, over 900 000 doses of COVID-19 vaccine were administered which was 36% of total doses administered during the whole period of 2021. During the first phase of the rollout, the country targeted the frontline workers, including health care workers; the elderly people; and people with chronic health conditions for vaccination.
Reaching zero-dose children in fragile settings: scaling up immunization services show progress
In 2021, despite a continued disruption of essential health services including childhood immunization programme to the extent of 5 to 20%, WHO made an aggressive effort to bring the immunization services back to pre-COVID-19 time by strengthening both fixed and outreach services including organizing accelerated campaigns for measles. As a result of these intensified campaigns, a total of 98,000 zero-dose children out of 170,000 to 180,000 children who normally miss out childhood routine immunization every year were reached and received penta 1 and measles vaccine. This was the highest number of zero-dose children ever reached out in the country in the recent history. In addition, WHO and the United Nations Children’s Fund (UNICEF) continued to support the country to improve routine immunization of children using the opportunity of rollout of COVID-19 vaccines in the country using both fixed and outreach services. In 2021, WHO also responded to a number of localized measles outbreak promptly and timely thereby containing the outbreak before it spread to other districts or locations. A total of 3,500, 000 children under 5 years received vaccines in 2021 as part of routine immunization programme supported by WHO and other partners.
Using innovation to accelerate impact: solar-powered medical oxygen systems saving lives in Somalia
When the first laboratory-confirmed case of COVID-19 was reported on 16 March 2020 in Somalia and the outbreak was raging across the country, none of the public sector hospitals in Somalia had medical oxygen available. Driven by the dire need for pure, high-grade medical oxygen, WHO country office scaled up availability of medical oxygen in the country to save lives. As part of this drive and in a display of strong international collaboration, the solar-powered oxygen concentrators were installed in the Hanaano General Hospital, Dusamareb in Galmudug State, early in February 2021.WHO collaborated with Grand Challenge Canada (GCC), one of the innovation funders on this intervention to set up the solar-powered medical oxygen system, the first of its kind, in the country .
In addition to the support provided by Grand Challenges Canada and the University of Alberta, WHO’s support to this innovative pilot project comes through collaboration across several departments embedded within 3 levels of the Organization – including the Innovation Team at the WHO headquarters, the WHO Regional Office for the Eastern Mediterranean and the WHO Somalia country office. This partnership came about through a new faciliatory role WHO has taken on that links country demands to innovation supply and assessment. Various UN agencies and implementing partners have provided support to turn this idea into a reality. WHO is working with the multi-partner-driven "Global Action Plan for Healthy Lives and Well-being for All" (SDG3 GAP) to match the demand and supply of life-saving oxygen in Somalia. On 29 March, the Deputy Special Representative of the UN Secretary-General and the UN Resident and Humanitarian Coordinator for Somalia (DSRSG/RC/HC), Adam Abdelmoula, and the WHO Representative for Somalia, Dr Mamunur Malik, visited the Hanaano Hospital in Dusamareb, Galmudug State of Somalia, to officially hand over this solar-powered oxygen plants to the Galmudug Ministry of Health. Since this 3 solar power-based oxygen stations were installed, 171 patients including children of different age and with different medical conditions received medical oxygen. Among these care seekers who received medical oxygen, 98% were discharged without any disability. It is estimated that pneumonia killed an estimated 15 165 children under 5 in Somalia in 2018 (about 21% of child deaths) – about 2 children every hour. While the global evidence shows that up to 35% of childhood deaths from pneumonia are preventable with the use of medical oxygen, the WHO country office in Somalia is hopeful that by forging strategic partnerships with innovators, funders, SDG3 GAP agencies and the private sector, demand for medical oxygen and innovation will increase, which will accelerate the impact of this new initiative in reducing deaths from childhood pneumonia as well as other medical conditions.
Making mental health services available at all levels of care: understanding the link between peace and mental health
In 2021, the WHO country office, successfully, completed a pilot project on mental health which was titled-“Improving psychosocial support and mental health care for conflict-affected youth in Somalia: a socially inclusive integrated approach for peace building”. through collaboration with Somali National University, the Federal Government of Somalia, International Organization for Migration (IOM) and the United Nations Children Fund (UNICEF). This project has supported health care workers to understand, address and provide more care for people in need of mental health support, as well as raise awareness about mental health issues. The project has also generated evidence on the interlinkage between mental health and peace, a topic that has not been well researched or studied anywhere in the world. The project has been supported by the peacebuilding fund of United Nations with WHO being the lead agency for this project.
Somalia has particularly been impacted by mental health challenges owing to decades of protracted conflict, which has severely disrupted social cohesion, broken down social norms and led to nearly one in every three Somalis suffering from some form of mental health condition. The project implemented by WHO will be catalytic in generating evidence how improving and delivering quality mental health services can promote peace, reconciliation and reintegration of radicalized and disillusioned population into the society and showcase how through task shifting and using community-based interventions, mental health services can eb scaled up in conflict settings.