Country profiles

Somalia

Overview

Somalia has a surface area of 637 657 km². The topography of the country varies from mountainous in the north, calcareous highlands in the west, and arid plateaus in the east. Current population estimates result in a population density barely in excess of one person per km². The population is relatively young, with 44% below the age of 15 years (1997) and 3.9% above the age of 65 (1997). The urban population makes up 33% of the total, with 17% rural and 59% nomadic. The total adult literacy rate and the female adult literacy rate, in 1995, were 24% and 14%, respectively. United Nations sources estimated the crude birth and crude death rates to be 45.5 and 18.3 per 1000 population, respectively, for 1997. Somalia has the world’s second highest infant mortality rate and the second highest rate of maternal mortality. These rates are estimated at 125.8 per 1000 live births (1997) and 160 per 10 000 live births (1990), respectively. The under-5 mortality rate was estimated at 265 per 1000 live births in 1997. Total life expectancy at birth is 46.2 years (1997), one of the lowest in the world.

The major health problems are the following: tuberculosis, communicable diseases (especially measles), diarrhoeal diseases (especially infant diarrhoea), malaria, schistosomiasis, tetanus, sexually transmitted diseases, respiratory infections, common obstetrical problems, anaemia and leprosy. The per capita gross national product in 1989 was US$ 170. Although reasonably endowed with natural resources that have significant economic potential, Somalia is designated by the United Nations as a Least Developed Country. The first point of contact for health care, at the village level, is the primary health care post, staffed by one locally recruited community health worker and one traditional birth attendant. Next in line is the primary health care unit, which serves from 10 000 to 15 000 persons and is staffed by one public health nurse, one nurse midwife and one sanitarian.

The district health centre, which is staffed by one senior physician among others, is responsible for four primary health care units and covers from 40 000 to 60 000 persons. The regional health centre is in effect the district health centre of the regional capital. Governmental health curative services were offered at district and regional hospitals.

Until recently, the primary health care programme was working in nine regions, with an additional seven regions receiving partial coverage. Because of security-related deteriorations in various regions and the subsequent withdrawal of various donor agencies during early 1990, primary health care coverage only partially existed in nine regions. Now, with the total collapse of all government structures as a result of recent conflicts, renewed effort will have to be made to assist in the establishment of government institutions and to endorse the private health sector which would recommit its support for health for all .

In 1989, the Ministry of Health was allocated 2.95% of the government’s regular budget. While 67% of the total health budget came from external aid in 1984, 95% of the utilized budget came from this source during 1990. In 1990, over 79% of the Ministry of Health’s financial resources were allocated to Mogadishu, the capital, alone. Many health programmes suffered serious setbacks due to lack of funds and rising costs. The implementation rate of health projects was as low as 35.3%.

In 1990, Somalia had a reported ratio of 0.6 physicians per 10 000 population and four nurses per 10 000 population.

Since 1988, there has been a marked increase in the urbanization of health care in Somalia-there has been a reported increase in human resources and facilities in urban areas resulting in a more severe inequity between urban and rural areas.

Regional hospitals varied in size, from 50-to 200-bed capacity. Each of the 18 regions had one regional hospital and there were two public hospitals in the Banadir Region. The specialized hospitals numbered 17, comprising 10 tuberculosis hospitals, three mental hospitals, two leprosy hospitals and one paediatric and obstetric hospital. The district hospitals followed more or less the administrative map of the country. The usual capacity ranged from 10 to 20 beds. In 1988, the total number of beds reported was 5857. As a result of the current (1990-91) conflict in Somalia, few of the urban hospitals are now functioning and virtually none of the rural ones is operational. In addition to hospitals, there were 411 primary health care posts, 50 primary health care units and 94 maternal and child health centres reported at the end of 1990.

Financial, as well as human, resources were inadequate, and Somalia depended almost entirely on external sources for health financing.

Resource distribution was becoming more inequitable and human resources shortages were becoming more severe. Apart from security problems and the almost total absence of government-provided compensation to Ministry of Health employees, weaknesses in the national logistic, transport and communication networks were probably the main obstacles to the implementation of primary health care in Somalia. Moreover, the Ministry of Health’s coordination of individual agencies implementing primary health care activities and the coordination between agencies was inadequate.

Furthermore, due to the recent conflicts in Somalia, it is widely perceived that no governmental or institutional infrastructure exists in the country capable of supporting the development of expansion of primary health care. Additionally, the very fabric of society, as well as social and family relationships, have suffered serious damage as a result of these conflicts and the resulting deprivations. With a very few exceptions, health for all activities must start again from zero.

MENTAL HEALTH

There is one mental hospital in the country, in Berbera on the northern coast. This hospital has patients far in excess of the beds and other facilities. The living conditions of the patients are dismal, the basic hygiene is deficient, psychotropic drugs are almost non-existent and often, the only treatment available is electroconvulsive therapy. The nursing staff is inadequate and poorly trained and as a result, the patients are still found with chains on their feet or chained to the wall. Opportunities for recreation and occupational therapy are practically non-existent. The criminal patients are mixed along with other patients.

The mental hospital at Berbera has patients living in cells 1 metre × 2 metres with iron bars and chains. There is no provision of medicines, clothes or even food. Whatever food the patients get is through public charity, which can be very erratic. There is no provision for any kind of activity by the patients, and activity is in fact discouraged because of there being only two auxiliary supervisors.

The psychiatric section at Forlinini Hospital, Mogadishu, is part of a chronic diseases set-up, which included tuberculosis and leprosy.

The mental section of Hargesia hospital provides an interesting combination of despair and hope. Like the other hospitals, it is deficient in basic amenities but the good thing is that is a part of the general hospital and has therefore a potential for becoming a model for a modern general hospital psychiatric unit.

There are five trained psychiatrists in the country. Four of them work in Forlinini hospital at Mogadishu. There is no psychiatrist at Berbera mental hospital. Three psychiatric nurses have been trained but only one works for the Ministry of Health and even he has no clinical responsibility. There is no clinical psychologist or psychiatrist social worker in the country.

Except for the three hospitals mentioned above and the private practices set up by the psychiatrists working there, modern psychiatric care is non-existent elsewhere in the country. The major referral hospital (Digfer), which has major specialities, including neurology and neurosurgery, has no psychiatric presence, even at outpatient level, and the services of the psychiatrists available in Mogadishu are not being utilized either at this hospital or other outpatient facilities in the capital. There is no tradition of liaison services in other facilities.

The whole structure of primary health care being set up in the country has no psychiatric input, though such input has been agreed in principle. Currently, the majority of the psychiatric patients are either unattended-living with their families or-receiving the very doubtful and untested attention of the traditional healers.

The country has made an important advance by banning the use of khat, but there is a concern that there might be a growing misuse of other psychoactive substances such as alcohol, opiates, psychotropic drugs and tobacco. There is no provision for prevention and treatment of drug abuse in the country.

The knowledge and understanding of the general public regarding the causes and management of psychiatric disorders is rudimentary and in general, quite archaic and false. Most people believe mental illness to be due to demons and spirits, and there is hardly any consolidated attempt at educating the public with the correct information and changing their attitudes.

Psychiatry is part of the medical curriculum at the University medical school. The teaching is, however, carried out by a visiting Italian psychiatrist who comes once a year for two to three months and imparts rudimentary theoretical knowledge. One of the Somali psychiatrists has a quasi involvement in the teaching programme, but his efforts are poorly coordinated with that of the visiting psychiatrist and clinical training is inadequate. A rudimentary theoretical knowledge is imparted to nurses at the nursing school.

Against this background, in 1983 and 1986, WHO short-term consultants visited Somalia. They reviewed the situation and formulated a national mental health programme in consultation with the mental health professionals of Somalia.

Objectives of the national mental health programme

• To provide minimal mental health care for all, taking into account not only the treatment and prevention of mental disorders, but also the promotion of mental health.

• To provide mental health principles in other spheres of life in work, in family interaction, community participation, for national growth and international participation.

Strategies for the proposed national mental health programme were to provide mental health care for all by integration of mental health into the general health programme, to provide graded training to various categories of workers at all these levels so that they can: recognize mental disorders and epilepsy; encourage early rehabilitation of the mentally ill and epileptics; provide mental health education to the community; and refer all such cases that cannot be managed by them to regional hospitals.

It was planned to create a mental health unit in the Ministry of Health. This unit will be headed by a trained psychiatrist and work in the context of a national coordination committee for mental health.

The national mental health programme also envisaged activities in the areas of mental retardation, upgrading of mental hospitals, drug dependence care, involvement of nongovernmental organizations, nursing training and research.

The civil strife and lack of resources has resulted in a lack of progress in any of the areas outlined above.