Annual report 2019 World Health Organization Somalia: progressing our new narrative

Progressing our new narrative ANNUAL R E P O R T 2019 WORLD HEALTH ORGANIZATION SOMALIA WHO Library Cataloguing in Publication Data Names: World Health Organization. Regional Office for the Eastern Mediterranean Title: Annual report 2019 World Health Organization Somalia: progressing our new narrative / World Health Organization. Regional Office for the Eastern Mediterranean Description: Cairo: World Health Organization. Regional Office for the Eastern Mediterranean, 2020 Identifier: ISBN 978-92-9274-427-4 (pbk.) | ISBN 978-92-9274-428-1 (online) Subjects: Health Status | Drugs, Essential | Immunization Programs | Communicable Disease Control | Emergency Medical Services | Universal Health Insurance | Somalia Classification: NLM WA 300 This publication was originally published under ISBN: 978-92-9022-368-9, 978-92-9022-369-6 © World Health Organization 2020 Some rights reserved. 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However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Photo credits: WHO/SOMALIA Progressing our new narrative Annual Report 2019 World Health Organization Somalia Bridging health gaps: WHO Somalia country office is working to promote better health for everyone, everywhere. W H O S O M A L I A A N N UAL R E P O RT 2 0 1 9 Foreword Abbreviations Essential Medicines and Pharmaceutical Policies Programme Expanded Programme on Immunization Health Cluster Health Emergency Programme HIV/AIDS Programme Malaria Control and Eradication Programme Neglected tropical diseases Polio Eradication Programme Tuberculosis Control Programme Universal health coverage External relations and partnerships 3 8 9 12 17 20 25 27 32 35 39 42 51 56 60 54 57 58 58 59 Business operations Acknowledgements Visit of the WHO Regional Director for the Eastern Mediterranean and Launch of the UHC Roadmap for Somalia New WHO country office for Somalia in Mogadishu Improved communication infrastructure Staff development and training Security management Contents W H O S O M A L I A A N N UAL R E P O RT 2 0 1 9 Foreword W H O S O M A L I A A N N UAL R E P O RT 2 0 1 9 3 a year of renewed hope Message from the WHO Representative As we come to the end of another year, we are proud to put on record some of the achievements that not only shaped a change in our narrative last year, but also renewed our hopes for a better future for the Somali people. In 2019, we made number of landmark achievements which had far-reaching impacts. These achievements have demonstrated our ability to bring about positive change and work collaboratively with others. The confidence that the Government of Somalia, donors and other partners are increasingly putting in us reflects our value and importance in leading the efforts to enhance the health sector in the country. WHO Somalia will continue to strive to meet the needs and expectations of our partners and increase cooperation, communication and collaboration to ensure improved health for the people of Somalia and to meet the health-related Sustainable Development Goals (SDGs). Achieving universal health coverage (UHC) in a complex and fragile setting such as Somalia is an enormous undertaking. Nonetheless, we have taken up this challenge. In September, during the visit of the WHO Regional Director for the Eastern Mediterranean, Dr Ahmed Al-Mandhari, the Ministry of Health and Human Services officially launched the UHC roadmap, which was developed through extensive consultation with and technical oversight by the WHO country office. The roadmap serves as a strong commitment from the Government to work with all partners to achieve more equitable access to health care and better health outcomes for all Somali people. Among the UN family in Somalia, our country office will continue to take the lead in providing technical support to the government to implement the roadmap in the coming years. W H O S O M A L I A A N N UAL R E P O RT 2 0 1 9 4 on the humanitarian–development nexus. The review will be a milestone to better understand the policy transition of the health agenda from a humanitarian focus to one on long-term development. This work has already earned recognition from our partners and demonstrates how we are building evidence to guide and validate our future work in the country. In November 2019, in partnership with UNICEF and the Federal Ministry of Health and Human Services, WHO launched the first nationwide, integrated immunization campaign for polio and measles, which targeted over 2.6 million children. Our vaccinators worked hard, going door-to- door in each community to reach every child with life-saving measles and polio vaccines, deworming tablets and vitamin A supplements. The results have been encouraging and this campaign has set a precedent for future integrated approaches that target children in the country with life- saving interventions. The Country Cooperation Strategy of WHO Somalia is now nearly finalized. The strategy highlights our hopes for a better future in this crisis-torn country, and also our roadmap to achieve the triple-billion targets of WHO’s Thirteenth General Programme of Work 2019−2023 (GPW 13). Our systematic approach to achieve health goals combined with the collective strength and technical competence of the country office team will be pivotal in rolling out the Country Cooperation Strategy in 2020, towards supporting health authorities in their efforts to achieve UHC. In 2019, we launched a new project co-partnering with the International Organization for Migration (IOM), United Nations Children’s Fund (UNICEF) and the Somali National University to improve mental health care and psychosocial support in Somali young people affected by conflict in the country. This innovative project will help to build evidence and links between mental health and peacebuilding at the community level. The project is supported by the UN Peacebuilding Fund. The devastating floods in Beletweyne and other neighbouring areas towards the end of 2019 was a testing time for all of us. Nevertheless, we successfully put our emergency response operations into swift action, mitigated adverse health effects and prevented potential disease outbreaks. This rapid and surge response prevented any deaths associated with the health effects of the floods. We also successfully rolled out the Early Warning, Alert and Response Network (EWARN) in flood-affected districts, which helped stop any large-scale disease outbreaks. EWARN is the only source of disease surveillance data to monitor, detect and rapidly respond to epidemic threats in these affected areas. In 2019, we embarked on an in-depth review of the humanitarian–development nexus in the Somali health sector. The review assessed the current aid structures for humanitarian and development financing as well as the potential effect that multiyear predictable funding would have on meeting the health-related indicators of the SDGs. Among WHO country offices, ours was the first to have commissioned such a study W H O S O M A L I A A N N UAL R E P O RT 2 0 1 9 5 Our work in keeping the country free of wild polio virus since 2014 in such a challenging and fragile setting received the WHO Director- General’s team award for excellence in 2019. This is a recognition of our abilities to achieve results even in difficult and complex circumstances. This recognition and the inspiring work in one programme area will show the way forward and provide hope for other programmes that we can all bring about positive change and sustain progress. This was also a year where our communication and donor relations work gained new momentum. In 2019, we built the trust of our donors and partners by becoming increasingly visible and demonstrating the positive impact of our work. Several new and regular publications, such as the Annual Report, quarterly technical updates, weekly epi-watch reports, staff newsletters and new documentary videos, have been posted regularly on our website and social media platforms. Being visible is a sign that we are growing in strength and reaching out to external audiences to highlight our challenging work in Somalia. We thank all our partners and donors for their active and ongoing support. As our journey continues, we will endeavour to build on innovation, while making measurable results the basis of everything we do to improve health outcomes for the Somali population. As part of our efforts, we initiated a number of changes in 2019 to make our work more cohesive, connected and collaborative. In 2020, we expect to see the results of these changes in different ways, for example: functional integration creating more synergies between the different programmes and diseases control activities that we support; better information management especially for monitoring the SDGs and measuring the impact of our work; sustained drive for improved communication and visibility; and alignment of our work with the Country Cooperation Strategy, GPW 13, 2030 SDGs and UHC roadmap. A respectful, happy and efficient workplace for all the staff of the WHO country office and an efficient and effective organizational structure and work strategies are vital to drive forward all these important changes. Finally, I thank all the WHO country office staff for their dedication and commitment, without which we would have failed to maintain the momentum of change. Change is an inevitable part of any organization and our staff have embraced “Be the Change” to drive their motivation, their collective success in 2019, and their renewed hope for a better future for the people whom they serve. Dr Mamunur Rahman Malik WHO Representative Somalia W H O S O M A L I A A N N UAL R E P O RT 2 0 1 9 6 W H O S O M A L I A A N N UAL R E P O RT 2 0 1 9 7 Acquired Immunodeficiency Syndrome Circulating Vaccine-Derived Poliovirus Disability-Adjusted Life Years District Health Information System Expanded Programme on Immunization Early Warning, Alert and Response Network The Vaccine Alliance Global Polio Eradication Initiative General Programme of Work Human Immunodeficiency Virus Inactivated Polio Vaccine International Organization For Migration Immunization Coordination Committee monovalent Oral Polio Vaccine Non-Governmental Organization United Nations Office for the Coordination of Humanitarian Affairs Primary Health Care Sustainable Development Goals Somalia Humanitarian Fund Sexually Transmitted Infections Tuberculosis Universal health coverage United Nations United Nations Population Fund United Nations Children’s Fund World Health Organization AIDS CVDPV DALYs DHIS EPI EWARN GAVI GPEI GPW HIV IPV IOM ICC mOPV NGO OCHA PHC SDGs SHF STIs TB UHC UN UNFPA UNICEF WHO Abbreviations W H O S O M A L I A A N N UAL R E P O RT 2 0 1 9 8 Essential Medicines and Pharmaceutical Policies Programme 9 Pharmacovigilance unit established within the Medicines Regulation Authority National Supply Chain Management System developed Somali Medicine Law and Drug Act developed regulation and monitoring of antibiotic use to avoid irrational use without a prescription from a medical doctor, among other activities. Second, during the 2019 World Antibiotic Awareness Week, the programme produced advocacy materials (messages, brochures and videos) for the public that explained the proper use of antibiotics, the fact that bacteria, viruses and funguses can all develop resistance to medicines over time thus making these medicines ineffective, and the public health problems that arise from antimicrobial resistance. The programme also published documents on essential medicines and pharmaceutical strategies and guidelines which were shared with the local and national health authorities to be used as references in developing national guidelines and strategies. Third, the programme issued rapid alerts for substandard and falsified medicines – an initiative in which WHO disseminated surveillance information on pharmaceutical products to essential medicines and pharmaceutical programmes at the country level in order Promoting access to safe, life-saving and affordable medicine WHO Somalia’s Essential Medicines and Pharmaceutical Policies Programme provides training, policy advice and technical support to the Ministry of Health and Human Services, including the Medicines Regulatory Authority. The programme also supports the drafting of important laws related to medicines, such as the Somali Medicines Law and Drug Act, which was enacted in 2019 to ensure the quality of medicines and better regulation of the private pharmaceutical sector. As a result of these and other activities, WHO had a number of successes in 2019. First, the Essential Medicines and Pharmaceutical Programme assisted in the development of the Somali National Action Plan on Antimicrobial Resistance, which led to the formation of the Multisectoral Coordination Group and a technical working group on antimicrobial resistance (a programme that continues up to now), which assist with oversight, In 2019, WHO’s work in Somalia to enhance access to essential, safe and affordable medicines, as part of the effort to achieve universal health coverage, centred around surveys, training and other capacity- building activities as well as policy support for promoting rational use of medicines, management of the national supply chain system and improving the regulatory functions of the health authority. W H O S O M A L I A A N N UAL R E P O RT 2 0 1 9 1 0 Medicines Regulatory Authority, which deals with collecting reports on adverse drug reactions, or side effects (including caused by the use of fake, or substandard medicines), from healthcare professionals, patients and communities in general; (ii) using the WHO tool for surveillance and monitoring of substandard and falsified medical products and medicines for 34 people (19 males, 15 females); (iii) medical device regulation, the role of regulators in addressing antimicrobial resistance, and pharmacovigilance for 15 people (8 males, 7 females); (iv) using the Somali standard treatment guidelines for hospitals and health centres for 101 doctors and other medicine prescribers (65 males, 36 females) – 33 in Mogadishu, 34 in Baidoa and 34 in Hargeisa and (v) management and storage of essential medicines for 34 people (19 males, 15 females) working in non-governmental organizations (NGOs) and the private sector, including Somali medicine wholesalers and members of the Somaliland Pharmacists Association. As a result of these initiatives in 2019: the regulatory capacity of the Medicines Regulatory Authority was strengthened in the area of pharmacovigilance and ability to report on substandard and falsified medicines; cooperation between medicine wholesalers, importers and the Medicines Regulatory Authority was enhanced (with the longer-term vision of creating a nationwide drug-registration system); as a result of advocacy and awareness-raising meetings, quality of medicines improved in Somaliland and the capacity of the National Supply Chain Management for warehouse management was improved. to trace falsified and substandard products circulating in the country. In this way, the Medicines Regulatory Authority could be alerted so it could take appropriate action to verify the availability and quality of these products, and report their findings using the WHO tool for global surveillance on substandard and falsified medicines. Fourth, the programme provided technical assistance and guidance to the activities of the National Supply Chain Management, the Supply Chain Technical Working Group and warehouse management. This included the development of national guidelines on donations of medicines, destruction of expired medicines and supplies, safe disposal of unwanted pharmaceuticals, and improvement of storage conditions of medicines and health products. Fifth, the programme, together with the Ministry of Health and Human Services, undertook a number of important training activities in 2019, including on: (i) developing and training for 20 people (14 males, 8 females) in a Pharmacovigilance Unit, within the W H O S O M A L I A A N N UAL R E P O RT 2 0 1 9 1 1 Expanded Programme on Immunization 1 2 628 vaccination centres established 462 050 (77% of the target) children (< 1 year) received three doses of the pentavalent vaccine 4 442 suspected measles cases detected aspects of immunization management (e.g. planning, communication, immunization sessions, cold chain, data, supportive supervision, monitoring and budgeting) for EPI managers at national and regional levels. WHO also trained about 900 health ministry staff (361 males, 539 females), mostly vaccinators and some district management team members, on immunization practices to improve their knowledge and technical skills. The EPI team also conducted biannual EPI zonal reviews and quarterly regional and district reviews in Federal Member States, Puntland and Somaliland to assess performance, determine lessons learnt, share achievements, and identify and overcome gaps in, for example, immunization-related activities such as routine immunization, outreach approaches and campaigns. The Interagency Coordination Committee for Immunization, which includes different ministerial sectors in the Federal Member States, Puntland and Somaliland, was also established to improve coordination and oversight of EPI-related activities. In addition to this Making every child count WHO is responsible for implementing the Expanded Programme on Immunization (EPI) across Somalia in close collaboration with the Ministry of Health and Human Services and other United Nations (UN) agencies, particularly the United Nations Children’s Fund (UNICEF). The EPI provides technical guidance to the health ministry on vaccines; immunization and cold chain management, and supports the ministry in developing policies and guidelines related to the EPI, which collectively contribute to health systems strengthening. To this end, the EPI health systems strengthening unit had a number of important achievements in 2019. For example, in addition to having placed 15 technical officers (13 males, 2 females) in the health ministry to provide technical support and policy advice, WHO also conducted a training-of-trainers course for 36 health ministry staff on the mid-level management module to improve their EPI managerial and technical skills, and develop their capacity to deliver such training to regional and district level stakeholders. This module is a training package that covers all WHO works with the health authorities and other partners to reach every child with life- saving vaccines. Despite a steady increase in routine immunization coverage over the past year in Somalia, children in hard-to- reach communities miss out on these life- saving vaccines. In 2019, between 140 000 to 170 000 children under 1 year living in these areas did not receive any vaccine. W H O S O M A L I A A N N UAL R E P O RT 2 0 1 9 1 3 challenges faced by the country, the disease situation has improved recently. While more than 30 000 suspected measles cases were reported in 2017, such cases were reduced to 4500 in 2019, which shows improved immunity. As a result, more children are now protected against deadly and preventable diseases, and the frequency of outbreaks of vaccine-preventable diseases has decreased. Improved surveillance capacities have also contributed to this decrease. Furthermore, the commitment and ownership of the Ministry of Health and Human Services in these areas has increased substantially through coordination and review meetings, capacity-building and training activities, and direct participation in supporting vaccination campaigns on the ground. policy-making support, WHO expanded surveillance of vaccine-preventable diseases across all accessible districts in Somalia by establishing at least one sentinel site for measles case-based surveillance and providing support to three laboratories for confirmation of measles cases. As a result of these activities, more than 1.1 million children under 5 years were vaccinated during an integrated polio and measles campaign in Jubaland, Hirshabelle, South West and Galmudug states – an initiative which also provided vitamin A supplements and deworming with albendazole. Although Somalia is still at risk of disease outbreaks, including of vaccine-preventable diseases, and despite the low EPI coverage in previous years because of the many W H O S O M A L I A A N N UAL R E P O RT 2 0 1 9 1 4 Improving EPI coverage through innovative structures Baidoa, a town in South West state, has a population of about 650 000 people, including around 400 000 internally displaced people. Unfortunately, vaccination coverage in Baidoa has been low compared with national averages. For example, coverage was only 53% for the pentavalent 3 vaccine (a vaccine against diphtheria, pertussis, tetanus, Haemophilus influenzae type B and hepatitis B) by the third quarter of 2019, which was much lower than the national average of 74%. Furthermore, measles coverage was only 52% in the same time period compared with the national average of 67%. One of the reasons for these large differences was limited outreach activities. In an innovative effort to overcome this challenge, WHO’s EPI team joined forces with the WHO polio and emergency teams to plan outreach activities using the district field assistant structure – where geographical areas are assigned to district field assistants who manage the planning and logistical requirements of their area. In total, 38 vaccination teams (comprised of one vaccinator and one social mobilizer) were deployed to carry out vaccinations 2 days a week over a 3-month period. As a result, 31 900 additional children under the age of 1 year received all vaccines, including Bacillus Calmette–Guérin (BCG), pentavalent 3, oral polio vaccine, inactivated polio vaccine and measles at outreach sessions. Through these activities, pentavalent 3 vaccine coverage increased to 71% and measles vaccine to 69%. Where possible, similar approaches will be used in the future in order to further improve vaccination coverage across Somalia. W H O S O M A L I A A N N UAL R E P O RT 2 0 1 9 1 5 Video Interview with Salado: http://www.emro.who.int/somalia/information-resources/multimedia.html 1Measles. Fact sheet. Geneva: World Health Organization; 2019 (https://www.who.int/news-room/fact-sheets/detail/measles). Vaccines are good for our children Salado Yaris Mohamed is a mother of eight children and a small-scale vegetable retailer. Her daily income is the only source for putting food on the table for her children. When her youngest daughter, Hafsa, became very ill, Salado faced a difficult situation; not only would hospitalization of her daughter be a financial burden, but it would also force her to close her shop because someone is required to remain with a child in hospital. At the same time, she did not want to take any chances with Hafsa’s health, having already lost three children to measles in the past. Fortunately, at this point, Salado learnt that Banadir hospital provided free health care. After assessment at Banadir hospital, Hafsa was immediately admitted as she had contracted measles. Hafsa received a blood transfusion and was put into isolation for further treatment. Her condition improved within a few days – a great relief to Salado. “I believe the measles vaccine is very good and these vaccines protect our children. I was not aware of this, but now I know vaccines are good for our children. I am aware of the benefits now more than before and I will vaccinate all my children. I also ask other parents to vaccinate their children before they become sick,” said Salado Measles is a highly contagious disease and a major killer of children under 5 years of age. Young children are vulnerable to the complications of the disease, including pneumonia (the most common cause of death in children with measles), encephalitis, ear infections (that can lead to permanent deafness) and diarrhoea. Even though a safe and cost-effective vaccine is available, measles caused more than 140 000 deaths globally in 2018, mostly in children under the age of 5 years.1 Routine measles vaccination for children, combined with mass immunization campaigns in countries with high case and death rates, are key public health strategies to reduce global measles deaths. WHO Somalia is working closely with the Ministry of Health and Human Services, UNICEF and other partners to improve such vaccination initiatives across the country. W H O S O M A L I A A N N UAL R E P O RT 2 0 1 9 1 6 35 nongovernmental organizations enrolled in the ReportHub US$ 26.5 million disbursed from the Somalia Humanitarian Fund and the Central Emergency Response Fund (CERF) 100 partners coordinated for humanitarian health interventions Health Cluster 1 7 supporting partners in jointly assessing humanitarian needs and agreeing on prioritized interventions. In 2019, the Cluster, together with the Office for Coordination of Humanitarian Affairs, facilitated the allocation of about US$ 26.5 million of humanitarian funds under the Somalia Humanitarian Fund and the Central Emergency Response Fund in response to the sudden onset of drought and flood emergencies. With this funding, partners were better able to deliver life- saving health care services and disease control activities in the hardest hit areas. WHO contributed to this success by providing technical guidance to Health Cluster partners and to public health emergency officers at the state level, who lead operational coordination and response activities. Health Cluster activities have provided an interactive forum for increasing engagement and partnerships between humanitarian actors and health authorities at national and state levels. This engagement has enabled enhanced Supporting healthy humanity The Health Cluster works closely with the Ministry of Health and Human Services and state-level authorities on the coordination of humanitarian interventions. To this end, the Health Cluster hosts monthly coordination meetings at the national level (in Mogadishu), Federal State level and regional level. The Cluster team leads over 100 partners, including UN agencies, international NGOs, national NGOs and observer agencies, in strategic planning for and response monitoring of protracted crises and acute emergencies, including environmental emergencies (e.g. droughts and floods), across Somalia. In addition, as part of its information-sharing mandate, the Cluster produces monthly bulletins, partner-presence mapping and other situation updates, such as bi-weekly flood response updates, which consolidate details and needs on the most affected districts. In terms of strategic planning, the Health Cluster leads the development of the health components in the Somali Humanitarian Programme Cycle and Humanitarian Response Plan, by As the Health Cluster lead, WHO’s focus in 2019 in Somalia shifted to operationalization of the humanitarian- development nexus to improve access to and quality of health services through a policy transition of the health agenda from a humanitarian emphasis to one of long- term predictable development W H O S O M A L I A A N N UAL R E P O RT 2 0 1 9 1 8 ReportHub In 2019, the Health Cluster rolled out ReportHub – an innovative online reporting platform that simplifies the uploading of data for monthly reporting and allows monitoring of the activities of different partners. Overall, the system enables the Cluster to monitor humanitarian health action by partners supporting, or directly providing, services to affected populations, down to the district level. The information uploaded by partners allows for better planning, identification of gaps, and monitoring of the effects of the response. To date, 35 international NGOs and national NGO partners are reporting on the platform. In addition to ReportHub, the Health Cluster, with support from the WHO country and regional offices, rolled out an emergencies project on gender-based violence, with the aim of improving services for survivors of gender-based violence and intimate partner violence in Somalia. An analysis of gender-based violence in the country and related health services was carried out, which led to an action plan for 2020 on gender- based violence in health in Somalia, for both WHO and the Health Cluster. collective action against crises and joint strategic planning based on information and knowledge-sharing to improve delivery of humanitarian services. Advocacy has also increased resources and actions aimed at improving health services for: survivors of gender-based violence; mental health and psychosocial support; and equity and safety in health service delivery. W H O S O M A L I A A N N UAL R E P O RT 2 0 1 9 1 9 Health Emergency Programme 620 000 people living in high-risk areas protected against cholera 4.7 million vulnerable people received emergency health care 535 Early Warning, Alert and Response Network (EWARN) sites established 2 0 As a result, 249 847 people (106 015 males, 143 843 females) received life-saving PHC services. Furthermore, support to nutrition stabilization centres improved case management of severe acute malnutrition (SAM) with medical complications. WHO provided guidelines, medical supplies and equipment (25 SAM kits to 12 centres, capable of treating 1250 SAM cases over a 3-month period), and training to 116 health workers (69 males, 47 females) from 37 stabilization centres. In total, 25 244 malnourished children (18 730 of whom were newly admitted) received treatment, with a cure rate of 92.2%. This rate is above the Global Nutrition Cluster’s SPHERE threshold of 80% for SAM treatment outcomes in emergencies. WHO also supported training of health workers in diagnosis and management of SAM with medical complications. With regard to escalations in conflict and security-related incidents, 41 288 injured people (28 902 males, 12 386 females) were reported across the country, more than 60% of whom had non-blast related injuries. WHO support included procurement and Protecting the vulnerable In 2019, the WHO country office for Somalia, in collaboration with the Ministry of Health and Human Services, responded to many health emergencies as a result of conflict, drought and flooding. The focus was on prevention, preparedness and response to communicable disease outbreaks, mass casualty incidents (e.g. explosions) and provision of support to PHC services (including integrated health and nutrition services), with the overall aim of reducing avoidable morbidity and mortality. Emergency drought and flood response activities led to the training and deployment of 628 health workers (350 males, 278 women) and the establishment of 20 district-level rapid response teams, which contributed to surveillance of outbreak-prone diseases, and verification, investigation, case management (including for malnutrition) and reporting of diseases. In 2019, WHO’s health emergency programme supported the health authorities in Somalia to improve surveillance for early detection of health threats and avert large epidemics in flood- and drought-affected areas by ensuring timely access to health care and a rapid response to small-scale surges of epidemic-prone diseases. In addition, many vulnerable populations, especially internally displaced people, have had improved access to health care and other public health interventions W H O S O M A L I A A N N UAL R E P O RT 2 0 1 9 2 1 distribution of medical supplies (about 130 metric tons) that could help treat an estimated 120 000 people suffering from different life-threatening conditions. In addition, WHO and the Ministry of Health and Human Services together achieved a number of other important milestones. A vaccination campaign with oral polio vaccine was undertaken in six high-risk districts (Afgooye, Balad, Hamar Jabjab, Heliwa, Khada and Kismayo) which provided 616 726 people (264 550 males, 352 176 females) aged 1 year and above with two doses of the vaccine. Furthermore, the number of health facilities reporting to the Early Warning Alert and Response Network (EWARN) was expanded from 451 to 535 (84 new reporting sites), thereby increasing population coverage from 5.4 million to 6.5 million people. The National Action Plan for Health Security, 2020–2023 – a 5-year, government-owned strategic plan for implementing the core capacities on preparedness and response to health emergencies of the International Health Regulations 2005 – was also prepared and is under review by the health ministry. Finally, capacity in Somalia’s national public health laboratories was enhanced – three technicians were trained on management of cholera samples and another 26 health workers, surveillance officers and laboratory technicians (22 males, 4 females) were trained on stool sample collection, packaging and shipment. For suspected cases of dengue and chikungunya, WHO also supported sample shipments to reference laboratories in Nairobi, Kenya for testing and diagnosis. The impact of these activities has helped to alleviate some health challenges, gaps in the response to health emergencies and crises across Somalia. EWARN expansion has reduced the risk of disease outbreaks, through early detection and response capacities, including through deployment of rapid response teams and improved diagnosis capacities in laboratories. Vaccination campaigns with oral cholera vaccine have helped prevent mass cholera outbreaks, while improved management of SAM with medical complications has helped to save the lives of over 25 244 children suffering from this extreme form of malnutrition. Needless to say, such efforts have helped contribute to a reduction in avoidable morbidity and mortality across Somalia during 2019. W H O S O M A L I A A N N UAL R E P O RT 2 0 1 9 2 2 Integrated emergency mobile health teams and EWARN During 2019, WHO supported the establishment of integrated emergency mobile health teams – the first such teams for WHO in Somalia – which provided health emergency response support during the floods and drought in many districts. The teams reached more than 249 000 people with PHC services integrated with mental health care support. In addition, EWARN, which started as a slow and complicated paper-based system, has now evolved into an efficient platform for electronic reporting, which is capable of collecting and disseminating disease surveillance information in real time. Currently, 535 health facilities can directly enter data into a mobile application linked into the EWARN system. In the absence of any other type of reliable disease surveillance system in Somalia, EWARN plays a critical role in supporting disease control efforts across the country. W H O S O M A L I A A N N UAL R E P O RT 2 0 1 9 2 3 next morning. Immediately following her examination, Nadifa received oral rehydration salts, was monitored for 2 hours and then received additional oral rehydration salts, as well as zinc and antibiotics to treat the diarrhoea. The team also advised me on hygiene, sanitation, administration of oral rehydration salts, breastfeeding, and prevention measures to avoid contaminations at home. Nadifa has made a full recovery and I am very grateful to WHO for the supportive hand it has provided to sick people in flood-affected communities. My name is Farhia Hassan. My family and I were displaced by the severe floods that that occurred in Beletweyne district, forcing us to take refuge on higher ground in Eljale village. One day, my child, Nadifa, contracted an illness, which gave her diarrhoea, vomiting and loss of appetite – she stopped breastfeeding. Because floods had cut off roads and submerged health facilities, forcing them to close, I was unable to take her to a hospital. However, when I heard that an integrated emergency mobile health team was providing services to displaced communities, I took Nadifa there the NADIFA’S STORY W H O S O M A L I A A N N UAL R E P O RT 2 0 1 9 2 4 HIV/AIDS Programme 91% of people with tuberculosis tested for HIV/AIDS 16 treatment centres established for antiretroviral therapy 3472 (32.5% of the national estimate) people living with HIV/AIDS received antiretroviral therapy 2 5 females) were being treated – a national coverage of 31.5% for all estimated cases of HIV infection. Moreover, despite supply challenges, 52% of all eligible patients had viral load testing to measure the amount of the virus in their blood. (Viral load testing is a new technology now available in Somalia to monitor HIV levels in patients.) The results of this testing showed that the proportion of patients whose virus levels had been satisfactorily reduced increased to 73.7% in 2019, up from 69.1% in 2018. In addition, 91.2% of tuberculosis (TB) patients were also counselled and tested for HIV, and 79.7% of those patients with both infections were put on antiretroviral therapy. The declining levels of HIV infection, as found in successive sentinel surveys, indicate the impact of both preventive and treatment activities, for which WHO support has been integral over the past 16 years. The activities supported and completed also demonstrate increased national capacity in sentinel surveillance, HIV testing and counselling, and laboratory testing, including advanced viral load testing. Ensuring universal access to prevention, treatment and care WHO, in cooperation with the Ministry of Health and Human Services, continued to support HIV/AIDS response activities in Somalia with training, supportive supervision, procurement and distribution of HIV rapid test kits, external quality assurance of HIV testing, and completion of a sentinel survey with data collection, analysis and writing of the report. In particular, the findings of the sentinel survey, which was done in Somaliland, Puntland and other Federal States of Somalia, showed a continued decline in HIV prevalence in pregnant women, from 0.24% in 2016 to 0.1% in 2018, and in people with symptoms of sexually transmitted infections, from 1.11% in 2016 to 0.23% in 2018. In addition, 614 new patients were started on antiretroviral therapy and, by the end of 2019, a total of 3472 people living with HIV (1430 males, 2042 Despite a decrease in the prevalence of HIV in pregnant women and people with symptoms of sexually transmitted infections in Somalia, the HIV detection rate remains low because of stigma and low awareness. WHO’s technical work with health authorities focuses on overcoming this challenge. The introduction of viral load testing in 2019 has enabled the country to monitor HIV levels in patients, which is essential for measuring the impact of control interventions and combatting the spread of the infection W H O S O M A L I A A N N UAL R E P O RT 2 0 1 9 2 6 Malaria Control and Eradication Programme 33 049 households in 39 villages covered by indoor residual spraying 189 335 people protected by WHO’s test, treat and track initiative 28 869 new cases detected and treated 2 7 programme review to assess programmatic issues and gaps so as to provide baseline data for Somalia’s National Strategic Plan 2021–2025 and for an application for a grant from the Global Fund. Therapeutic efficacy studies, an operational research study and insecticide resistance bioassay studies were also conducted by WHO in Bossaso; the results showed that there was no resistance to the current first- line malaria treatment. The programme, in collaboration with health authorities, established a functional outbreak response team to assess and control outbreaks and undertake response measures. For example, heavy rain and floods in different areas of the country increased breeding sites and hence densities of Anopheles and Aedes mosquitoes, which led to five malaria outbreaks in three districts (Borama, Beletweyne, Berdale) which affected more than 300 000 people. However, because outbreak response teams and other measures were already in place, these outbreaks were effectively managed. The programme also developed information, Aiming for a malaria-free status The WHO Malaria Control and Eradication Programme in Somalia, supported closely by the Global Fund to Fight AIDS Tuberculosis and Malaria, helps the health authorities in Somalia develop policy frameworks for malaria control and eradication. The programme also provides technical support for diagnosis, case management, vector control, and the development and review of malaria guidelines and strategies, and works to build health authority capacity by supporting training on case management and vector control (inside and outside the country) for national malaria health workers. During 2019, the Malaria Control and Eradication Programme, in close cooperation with the health authorities, carried out a number of key activities, including vector-control management using larval source management and on-time response to outbreaks. Furthermore, in line with the WHO mandate to monitor the efficacy of insecticides, guidelines were developed to monitor insecticides used for vector control in Somalia. In addition, the programme undertook a malaria The whole population of Somalia is considered at risk of malaria. However, in 2019, 51% of the country’s population was living in a high-risk transmission zone for malaria (> 1 case per 1000 population). WHO’s technical support in 2019 aimed to improve testing, treating and tracking of malaria cases to achieve low transmission W H O S O M A L I A A N N UAL R E P O RT 2 0 1 9 2 8 strengthened the capacity of national health workers to contribute to reducing the malaria burden. As a result of these activities, 324 226 people were tested for malaria with rapid diagnostic kits in 2019 (Fig. 1), 211 663 of whom were over 5 years of age and 112 563 were under 5 years. The total number of confirmed malaria cases was 28 869 – 20 366 (70.5%) over 5 years and 8503 (29.4%) under 5 years. Malaria data show the progress made during this biennium (2018/2019); the malaria incidence rate per 1000 population fell from 2.6 per 1000 in 2017 to 2.2 per 1000 in 2018 and further reduced to 1.97 per 1000 in 2019. All positive cases were treated according to the national treatment guidelines. education and communication materials, such as posters and pamphlets, to support information sessions for community educators. These sessions and materials empowered the educators to pass on messages on malaria throughout their local communities. Furthermore, use of the health information management system and the district health information system (DHIS2) led to an expansion of malaria case detection and improved reporting. To build capacity, the programme provided training on malaria case management (diagnosis and treatment) for doctors in the private health care sector, supported the participation of six entomology staff in the health ministry in malaria training in Singapore and Morocco, and trained 260 health professionals in malaria control and treatment. These training activities W H O S O M A L I A A N N UAL R E P O RT 2 0 1 9 2 9 Fig. 1: Suspected malaria cases tested and found positive, Somalia, 2014–2019 0 50000 100000 150000 200000 250000 300000 350000 Ja n M ar M ay Ju l Se p N ov Ja n M ar M ay Ju l Se p N ov Ja n M ar M ay Ju l Se p N ov Ja n M ar M ay Ju l Se p N ov Ja n M ar M ay Ju l Se p N ov Ja n M ar M ay Ju l Se p N ov 2014 2015 2016 2017 2018 2019 Malaria total tested Malaria confirmed Linear (malaria total tested) N um be r t es te d an d nu m be r c on fir m ed Year and month W H O S O M AL I A A N N UAL R E P O RT 2 0 1 9 3 0 Bossaso community. In addition, the WHO country office, in close cooperation with the WHO Regional Office for the Eastern Mediterranean, provided technical assistance to national authorities which led to the identification of a new species of mosquito in Bossasso – Anopheles stephensi. This species is suspected of being responsible for recurrent and prolonged malaria transmission in Bari, Puntland State. WHO will continue to monitor this species and its effects and take appropriate measures to mitigate its impact. Combatting malaria from a new species of mosquito – Anopheles stephensi For the past several years, malaria cases in Bossaso city have been increasing, affecting all of Puntland. However, considerable effort made by the National Malaria Control Programme and other partners led to a reduction in cases in 2019 (see Fig. 2). The slide positivity rate declined from 15.5% in 2017 to 9.0% in 2019. This achievement would not have been possible without the close cooperation and support of the local Fig. 2: Total suspected malaria cases and total found positive, Puntland, 2014-2019 Year and month Ja n M ar M ay Ju l Se p N ov Ja n M ar M ay Ju l Se p N ov Ja n M ar M ay Ju l Se p N ov Ja n M ar M ay Ju l Se p N ov Ja n M ar M ay Ju l Se p N ov Ja n M ar M ay Ju l Se p N ov 2014 2015 2016 2017 2018 2019 Malaria total tested Malaria confirmed 0 4000 2000 6000 8000 10000 12000 14000 16000 W H O S O M A L I A A N N UAL R E P O RT 2 0 1 9 3 1 N um be r t es te d an d nu m be r c on fir m ed Neglected tropical diseases 2.18 million people covered by mass drug administration and preventive chemotherapy for schistosomiasis and soil-transmitted helminths 3 new treatment centres established for visceral leishmaniasis 18 (out of 19) regions included in the mapping of neglected tropical diseases 3 2 delivery to halt the spread of neglected tropical diseases. Of the neglected tropical diseases listed by WHO as suspected or endemic in tropical countries, those which are most endemic in Somalia are leprosy, visceral leishmaniasis, schistosomiasis, soil-transmitted helminthiases, trachoma and lymphatic filariasis. In recent years, due to leprosy’s growing prevalence in Somalia, especially in southern regions, particular attention has been given to controlling this disease, which is a complex infectious disease mainly of the skin, peripheral nerves, mucosa of the upper respiratory tract and eyes. In 2015, only 107 people were affected by leprosy in Somalia, but this number rose to more than 2600 people across Somalia in 2018 (Fig. 3). This increase can be attributed to easy and frequent population movements and social mobilization which have led to reduced stigma about the disease and hence encouraged patients to seek health support as soon as they notice symptoms. Accelerating the fight against preventable tropical diseases In partnership with the health ministry, WHO is committed to managing and reducing the burden of neglected tropical diseases in Somalia. These diseases are a diverse group of communicable diseases that are prevalent in tropical and subtropical conditions. Overall, WHO’s programme on neglected tropical diseases aims to: (i) reach more people with campaigns to prevent the spread of leprosy and other neglected tropical diseases such as leishmaniasis, schistosomiasis and worm infections; (ii) train health workers to stop the spread of neglected tropical diseases; (iii) reach high-risk populations by conducting campaigns to offer drugs that prevent and treat leprosy and other neglected tropical diseases in camps for internally displaced people; and (iv) support health authorities in strengthening service About 5 to 6 million people in Somalia live in areas which are highly endemic for neglected tropical diseases (NTDs). In 2019, WHO’s accelerated efforts focused on the four most common NTDs in the country – leprosy, schistosomiasis, soil-transmitted helminths and visceral leishmaniasis. An improved screening programme for leprosy, an initiative to map NTDs and the introduction of preventive chemotherapy and mass drug administration for school-aged children and adults were the mainstay of these accelerated efforts W H O S O M A L I A A N N UAL R E P O RT 2 0 1 9 3 3 with health authorities and other partners, including by deploying more female health workers to reach families. The Government of Somalia is determined to provide multidrug treatment to all patients suffering from leprosy and, likewise, WHO remains committed to providing disability care for those in need and to eliminating all forms of discrimination against people affected by leprosy in the community. Between 2015 and 2019, there have been a number of important achievements related to neglected tropical diseases in Somalia. For example, in addition to the establishment of a neglected tropical disease unit in the health ministry, screening programmes for leprosy were implemented in regions that were most affected and in camps for internally displaced people. Furthermore, WHO conducted a mapping of neglected tropical diseases in 17 of the 18 regions of Somalia and, for the first time ever, preventive chemotherapy and mass drug administration were successfully implemented for school-aged children and adults were given praziqauntel and mebendazole. Finally, three new visceral leishmaniasis treatment centres were established, bringing the total to six centres in six regions of Somalia. WHO will continue to scale up efforts to eradicate leprosy and other neglected tropical diseases, in close cooperation Fig. 3: Leprosy cases by year, Somalia, 2015–2018 107 635 1576 2610 0 500 1000 1500 2000 2500 3000 2015 2016 2017 2018 N o. o f c as es Year W H O S O M A L I A A N N UAL R E P O RT 2 0 1 9 3 4 Polio Eradication Programme 3 circulating vaccine-derived polioviruses type 2 detected in 75 sewage samples 3 circulating vaccine-derived polioviruses type 2 detected in 361 cases of acute flaccid paralysis 3.14 million children (< 5 years) received polio vaccines 3 5 It targeted 2 917 349 children, 2 785 006 (95.5%) of whom were vaccinated. This campaign was followed by two subnational campaigns which targeted high-risk populations, including internally displaced people, nomadic populations and populations living in areas bordering inaccessible areas. The first of these subnational campaigns in April targeted 1 522 190 children in 39 districts. Of these children, 1 417 434 (93.3%) were vaccinated. The second campaign was in September and targeted 1 636 139 children, of whom 1 594 662 (97.5%) were vaccinated. In addition, WHO implemented an integrated measles, polio, vitamin A and deworming campaign in Hirshabelle, Galmudug, Jubaland and South West states: 1 288 097 children were targeted and 1 185 313 (92.0%) were vaccinated. WHO also conducted active and passive surveillance for acute flaccid paralysis across the country to detect polio cases. This surveillance was complemented by environmental surveillance that monitors polioviruses in sewer systems. In 2019, the Reaching every last child In line with the goal of the Global Polio Eradication Initiative, WHO in partnership with the Ministry of Health and Human Services and UNICEF are working to eradicate polio in Somalia, with a current focus on interrupting transmission of circulating vaccine-derived polio viruses type 2 (cVDPV2) and type 3 (cVDPV3). To this end, supplementary immunization activities are conducted in all accessible areas across the country, short interval additional doses are given in newly accessible areas and through vaccination points located in points of entry and exit to inaccessible areas. These activities target children under 5 years with the oral polio vaccine. WHO also supports the strengthening of routine immunization activities in which oral polio vaccines and inactivated polio vaccines are used to build population immunity. In 2019, one national polio campaign was implemented. Despite keeping Somalia free of wild poliovirus since 2014, WHO’s work in the polio programme has detected concurrent outbreaks of circulating vaccine-derived poliovirus (cVDPV) types 2 and 3. In 2019, WHO further scaled up its surveillance for acute flaccid paralysis and environmental surveillance to monitor the circulation of poliovirus in the environment. In addition, seven rounds of oral polio vaccination campaigns were organized to end the outbreak and to maintain the country’s status of being free of wild poliovirus W H O S O M A L I A A N N UAL R E P O RT 2 0 1 9 3 6 surveillance system detected cVDPV2 in three cases of acute flaccid paralysis in Puntland and Somaliland, and identified cVDPV2 in two healthy children in Puntland. In addition, three environmental samples were positive for cVDPV2 in Banadir in November and December. Furthermore, cases of acute flaccid paralysis from neighbouring Ethiopia were detected in Somalia. A cross- border notification was issued to Ethiopia so they could implement appropriate measures within Ethiopia (including case investigation and tracing of contacts). Cross-border partnerships have enabled the two countries, together with Kenya, to streamline outbreak response and synchronize immunization activities. This type of cross-border coordination has effectively minimized the risk of missing children in border areas and the emergence of vaccine-derived polio viruses in areas not covered by vaccination where populations interact with children from vaccinated areas. New initiatives by WHO during 2019 included the development of integrated and comprehensive microplans ahead of campaigns, and the use of third- party independent monitors to validate microplans in the field and to assess the quality of campaigns through post- campaign monitoring and lot quality assurance sampling. In taking this approach, WHO has been able to target beneficiaries more accurately and assess the quality of vaccination campaigns across the country. WHO’s polio vaccination activities in 2019 have helped susceptible children in Somalia build immunity against the polio virus and effectively protect them against the devastating disease of poliomyelitis. The work of WHO and other partners in the Global Polio Eradication Initiative in part contributed to the eradication of wild polio virus type 2 in 2015 and the certification of global eradication of wild polio virus type 3 in October 2019. This work is also helping in efforts to eradicate wild polio virus type 1 and interrupt transmission of cVDPVs in Somalia. Furthermore, Somalia experienced major outbreaks of wild polio virus type 1 before and the polio vaccination campaigns, together with the work done through routine immunization, enabled the country to bring these outbreaks to an end in 2014 and no new cases have been detected since. This is bringing both Somalia and the world closer to the eradication of poliomyelitis. W H O S O M A L I A A N N UAL R E P O RT 2 0 1 9 3 7 Open Data Kit: innovating data collection, monitoring and real-time decision-making During 2019, WHO strengthened its use of the Open Data Kit as a means of transmitting data in real time from the field to a central server at the country office during polio vaccination campaigns. The use of this kit improved the efficiency of data collection and real-time analysis to inform rapid decision-making which can then be relayed to the field teams to guide corrective actions. For example, where clusters of children were missed in some areas, field teams were notified so they could revisit the area to vaccinate those children. Use of the kit also improved timeliness and accuracy of reporting. In addition, the WHO Somalia country office developed a risk-scoring matrix which considers a number of critical parameters as a means to identify under-served populations and expand the traditional understanding of high-risk populations. Furthermore, the WHO Somalia team developed a tool to support decisions to revaccinate or carry out mop-up vaccination in poor performing areas. The tool computes a score using the results of desk and field validations at the district level, results of desk validation at the country level, results of field validation by third-party monitors, the administrative coverage for supplementary immunization activities, the results of post- campaign independent monitoring and the results of lot quality assurance surveys. W H O S O M A L I A A N N UAL R E P O RT 2 0 1 9 3 8 Tuberculosis Control Programme 90% treatment success rate maintained among newly diagnosed tuberculosis patients 44 centres established with an advanced GeneXpert tuberculosis diagnostic machine 96 centres established for tuberculosis treatment 3 9 machines have been installed across Somalia and access to diagnosis has been improved through a sputum mobility strategy, whereby TB centres without a GeneXpert machine can regularly send samples for testing to centres with the machine. Second, in addition to a TB culture laboratory in Mogadishu being put into operation, line probe assays 1 and 2 were installed in Hargeisa and Mogadishu TB culture laboratories so they are now capable of testing TB resistance to drugs used in the treatment of multidrug-resistant TB. Drug sensitivity testing using solid media was also introduced in Hargeisa. Third, the programme undertakes frequent capacity-building activities for both clinical and laboratory staff, and has trained over 347 health workers, including 181 from the Federal Government, 89 from Somaliland and 77 from Puntland. As a result of such activities, TB incidence in Somalia dropped from 285 per 100 000 in 2010 to 262 per 100 000 in 2018. Over the same period, TB mortality dropped to 67 per 100 000 and the estimated incidence of Scaling up the fight to end tuberculosis The WHO TB Control Programme, with financial support from the Global Fund, supports the Ministry of Health and Human Services by building capacity for TB diagnosis and treatment, at both federal and state levels. The programme also supports the development and adoption of TB policies and guidelines based on WHO recommended standards (e.g. guidelines on TB drug-safety monitoring, TB management and latent TB infection), manages drug distribution, and ensures there are no stock-outs of TB drugs. As a result of WHO’s efforts, the incidence of and mortality from TB have progressively decreased and TB case notifications have increased. These successes in the TB programme in 2019 can be attributed to a number of factors. First, the programme introduced an innovative diagnostic tool called GeneXpert in 2017, which is now the first-line method for testing presumptive TB cases in Somalia. In total, 44 GeneXpert WHO supports the health authorities in Somalia to accelerate efforts to end tuberculosis (TB) and reach all affected people with prevention and care. Because only 43% of people with TB in the country had access to treatment, a strategy to increase universal access to treatment and care was developed in 2019 which aimed to enhance TB diagnostic facilities and management of active TB cases, and update treatment guidelines for latent TB infection and multidrug-resistant TB W H O S O M A L I A A N N UAL R E P O RT 2 0 1 9 4 0 2Global tuberculosis report 2019. Geneva: World Health Organization; 2019 (https://apps.who.int/iris/bitstream/ handle/10665/329368/9789241565714-eng.pdf?ua=1). TB laboratory in Hargeisa Abdinasir Bilaal Abdi is 47 years old, married and comes from Bossaso. Although he had no family history of TB, nor contact with any TB-infected person, Abdinasir contracted the disease in March 2019 after moving to Zambia. Over a two-and-a-half-month period, he started to suffer from pain and breathing difficulties, and developed a severe cough. After visiting a hospital, fluid was found in Abdinasir‘s lungs as a result of TB. He was immediately started on TB treatment. While waiting for the fluid to be removed from his lungs, Abdinasir was advised to get treatment in Hargeisa, which he did in October 2019. In Hargeisa, he was diagnosed with multidrug-resistant TB and was admitted to Hargeisa’s treatment centre for multidrug- resistant TB on 1 November 2019 and started treatment that will last for 20 months. Since January 2020, after the fluid was removed from his lungs, Abdinasir has been making excellent progress and the TB bacterium is no longer in his sputum. Thus, the establishment of a TB culture laboratory in Hargeisa is having a very positive impact on the management of TB that is resistant to TB drugs. at 0.27%, while treatment coverage is 43% (up from 42% reported in 2018).2 multidrug-resistant and extensively drug- resistant TB dropped to 27 per 100 000. As of 2019, TB case fatality is estimated W H O S O M A L I A A N N UAL R E P O RT 2 0 1 9 4 1 Universal health coverage Guidelines on Integrated Management of newborn and Childhood Illness rolled out Reproductive, maternal, newborn, child and adolescent health strategy developed Roadmap for universal health coverage launched 4 2 is currently working in close collaboration with the United Kingdom Department of International Development, the World Bank and other UN agencies under the leadership of the Ministry of Health and Human Services to revise the essential package. This work will define a framework for the provision of essential health services to the Somali people at different levels, including the community level. Moreover, improving coverage of the Essential Package of Health Services will help Somalia move towards UHC. As well as these activities, a PHC measurement initiative developed both a master indicators list to measure progress in PHC and a PHC country profile of the existing PHC situation – these will be regularly updated to monitor developments in PHC and UHC in Somalia. A 5-year mental health strategy (2019– 2023) was also developed and endorsed by the Ministry of Health and Human Services; among other things, this strategy will ensure inclusion of mental health interventions in the Essential Package of Health Services and contribute to the integration of mental health and psychosocial support Making health count for everyone everywhere The WHO programme on universal health coverage (UHC) encompasses primary health care (PHC), health systems strengthening, reproductive, maternal, neonatal and child health, and noncommunicable diseases, including mental health and psychosocial support. During 2019, the UHC programme embarked on important initiatives which led to a number of important achievements that will help shape the future of the Somali health sector. For example, the UHC roadmap was developed, endorsed and launched, which shows commitment by the Government to move towards UHC in Somalia. In addition, with support from the UHC Partnership, local baselines, milestones and targets were established for all indicators linked with UN Sustainable Development Goal (SDG) 3. Furthermore, the Somali Essential Package of Health Services was reviewed in line with DCP3 (Disease Control Priorities) recommendations. In this regard, WHO Somalia, with support from WHO headquarters and the Regional Office, In 2019, WHO supported the health authorities in Somalia to revise and cost the Essential Package of Health Services (EPHS) in order to improve access to essential, good-quality health care at different levels. In the EPHS, primary health care has been recognized as the bedrock for achieving universal health coverage in vulnerable communities, women and children W H O S O M A L I A A N N UAL R E P O RT 2 0 1 9 4 3 into PHC services. A STEPwise survey of non-communicable diseases was also undertaken to identify the key risk factors of non-communicable diseases. Based on the findings of the survey, a strategy to tackle non-communicable diseases for Somalia will be developed. A 5-year reproductive, maternal, neonatal and child health (2019–2023) strategy was also developed in close consultation with the health authorities and other partners, which was endorsed by the Ministry of Health and Human Services. The development of this strategy was very timely as Somalia was selected as one of the countries to be supported by the Global Financing Facility on reproductive, maternal, neonatal and child health. Once implemented, this strategy will help improve maternal and child health outcomes. WHO Somalia also contributed to capacity-building: 115 health care providers (17 males, 98 females) from health facilities were trained on child- spacing guidelines that were adapted to the context of Somalia. This training helped enhance the capacity of health workers to provide birth-spacing services to the Somali population. Finally, national guidelines on the Integrated Management of Neonatal and Childhood Illnesses (IMNCI) were developed. A training-of-trainers course on the IMNCI guidelines was held in Hargeisa for 20 doctors (16 males, 4 females), in collaboration with UNICEF. IMNCI cascade training was then organized in Mogadishu for 20 health care workers (11 males, 9 females). In addition, the guidelines and other IMNCI material were printed and disseminated to health facilities across Banadir region. W H O S O M A L I A A N N UAL R E P O RT 2 0 1 9 4 4 Mental health for peacebuilding WHO, International Organization for Migration and UNICEF received US$ 1.5 million under the 2019 Youth Promotion Initiative of the UN Peacebuilding Fund for an innovative joint project to improve mental health and psychosocial support for young adults and adolescents in areas affected by conflict in Somalia. This project is the first of its kind in the country. Entitled “Improving psychosocial support and mental health care for conflict- affected youth in Somalia: a socially inclusive integrated approach for peacebuilding,” the project will provide mental health support to young people, mainly in Kismayo, Baidoa, Galkayo and Mogadishu. The project’s direct beneficiaries are estimated at 26 500 people, most of whom will be young people in camps for internally displaced people and their families, with an emphasis on reaching young women. The estimated number of indirect beneficiaries is 288 520 – entire communities in which the interventions are being undertaken and who will benefit from improved social cohesion and collective well-being. W H O S O M A L I A A N N UAL R E P O RT 2 0 1 9 4 5 strengthen health and social development. These opportunities include: an improved security and political situation; the potential to make use of humanitarian funds to tackle longer-term health and development needs, including by using primary health care as a key entry point for building an inclusive and more responsive health system; a growing number of development partners interested in health; a large private health sector and broad network of nongovernmental and civil society organizations which could help improve access to health care; improved availability of data that can help understand equity gaps through new health information systems (e.g. district health information systems, and logistics management and information systems); recent progress in mass immunization; and forthcoming Three decades of civil war and instability, coupled with natural disasters such as drought and floods, have weakened Somalia’s health system and contributed to some of the poorest health indicators in the world. These include very low coverage of essential health services, lack of access to safe water and sanitation, high prevalence of malnutrition, high burdens of communicable and noncommunicable diseases, high infant and maternal mortality, and very low life expectancy. About 70% of the country’s 15 million people live in poverty and over 2.6 million people have been internally displaced. In the face of these many challenges, the Government of Somalia is committed to taking advantage of opportunities to Somalia–overcoming fragility to build a stronger primary health care system W H O S O M A L I A A N N UAL R E P O RT 2 0 1 9 4 6 financing rounds of major global health funders, including several signatory agencies of the Global Action Plan for Healthy Lives and Well-being for All. The Somali National Development Plan for 2020–2024 identifies primary health care as the main approach to improving health outcomes in the country. In September 2019, Somalia launched its universal health coverage (UHC) roadmap for 2019–2023 that aims to: improve access to good-quality essential health services; reduce the number of people suffering financial hardship when accessing health care; improve access to and availability of essential medicines, vaccines, diagnostics and devices for primary health care; strengthen health emergency preparedness and response; and address the determinants of health to ensure that no one is left behind. The roadmap also aims to strengthen organizational capacity in the Ministry of Health and Human Services in areas such as the use of data and innovation, leadership, governance and advocacy, and financial management and human resources. Initial discussions among Global Action Plan agencies about opportunities for enhanced collaboration with Somalia to accelerate progress towards UHC through primary health care took place during a workshop of the Global Financing Facility in Addis Ababa in October 2019. The World Bank, United Nations Children’s Fund (UNICEF) and bilateral donors were closely W H O S O M A L I A A N N UAL R E P O RT 2 0 1 9 4 7 engaged in the discussions. Based on these discussions in the country, Global Action Plan agencies and other partners, including bilateral agencies, have continued to work on the development of a joint approach in support of the Government’s vision, including through discussions of the primary health care accelerator working group of the Global Action Plan. Five priority areas for enhanced collaboration between the Global Action Plan agencies and other partners have emerged: making, regulation, coordination, planning, management, contracting and use of data to guide decision-making. Improving access to a high-quality essential package of health services. WHO, UNICEF and other partners are already providing support to update the country’s health services package, focusing on the addition of prevention and community components and integrating selected noncommunicable diseases and mental health. The package now needs to be finalized and costed. Global Action Plan agencies and other partners recognize the country’s need for capacity-building and support to implement the package, potentially through the development of a joint Strengthening the role and capacity of the Ministry of Health and Human Services. This is essential in order to help tackle fragmented health service delivery and funding arrangements, and improve institutional capacity for policy- W H O S O M A L I A A N N UAL R E P O RT 2 0 1 9 4 8 plan. Delivery models also need to be revised to ensure that the package is available in hard-to-reach areas and for vulnerable populations, including internally displaced people. Financing the package is a key priority. Global Action Plan funding agencies including Gavi, the Vaccine Alliance, Global Fund to Fight AIDS, Tuberculosis and Malaria, Global Financing Facility and World Bank are committed to aligning their support with the national development plan and the UHC roadmap. These agencies are jointly exploring options for aligning their financing for health systems strengthening in Somalia to support primary health care and the essential services package through a range of approaches (including pooled funds). Strengthening emergency preparedness and response through UHC. Somalia is susceptible to emergencies, including natural disasters and disease outbreaks. It is now preparing for and responding to COVID-19. More effort is needed in the country to ensure that activities at the development and humanitarian nexus are coordinated and mutually reinforcing. Potential opportunities for enhanced collaborative support from Global Action Plan agencies include finalization and implementation of the national action plan for health security and ensuring the effective delivery of the essential package of health services and key commodities in humanitarian settings in the country. W H O S O M A L I A A N N UAL R E P O RT 2 0 1 9 4 9 Establishing a coordination mechanism for the Global Action Plan. The Global Action Plan signatories are working with WHO and UNICEF to set up an effective coordination mechanism for all health partners to support strengthening primary health care at the district level, and to ensure coherence and address service gaps. Mapping exercises on the availability of services and the health workforce have begun, which will determine options for scaling up primary health care services and also generate data for monitoring health- related SDGs at state levels. Harnessing the private sector for UHC. The private health sector, both health and pharmaceutical services, are largely unregulated in Somalia but have great potential to contribute to improving access to services and medicines, and achieving UHC. Global Action Plan agencies are exploring opportunities to support the development and operationalization of a strategy for the private health sector, such as helping to assess the current role of the private sector in service delivery, and developing adequate regulatory frameworks and contracting mechanisms. While the challenges to achieving UHC in Somalia are substantial, the opportunities to strengthen primary health care in the country are also great; for example stronger collaboration with Global Action Plan agencies to support the country’s efforts to achieve UHC and the health- related SDGs. W H O S O M A L I A A N N UAL R E P O RT 2 0 1 9 5 0 External relations and partnerships 628 new projects launched with external funding 15 new funding partners negotiated with for new projects 10 million dollars worth of new projects developed and set up 5 1 initiative, approved a US$ 1.5 million contribution for a joint project between WHO (lead), International Organization for Migration, UNICEF, Somali National University and the Ministry of Health and Human Services to improve psychosocial support and mental health care for young people affected by conflict in Kismayo, Baidoa, Galkayo and Mogadishu. The project is the first of its kind in the world and aims to be a socially inclusive integrated approach for peacebuilding. As part of this project, WHO has also reached out to and brought together a team of academic professionals from universities in Canada, Germany, the United Kingdom and the United States of America who will support a research study that will seek to link improvements in mental health with improved social cohesion and peacebuilding. Third, a € 1.2 million contribution was received from the Italian Development Cooperation Agency for a project to be undertaken in 2020 which aims to strengthen capacity at Hudur Hospital in the Bakool region by: Strengthening collaboration and trust During 2019, WHO Somalia worked to enhance its relations with and visibility among donors and partners. As a result, the office not only successfully secured several critical contributions, but also re-established positive relationships with former and new potential donors and partners. First, the Central Emergency Response Fund provided US$ 2.5 million to WHO during the drought and flood emergencies for emergency essential medical and health care for over 455 000 target beneficiaries (149 080 men, 149 148 women, 78 695 boys, 78 696 girls), including over 249 000 internally displaced people. Second, the UN Peacebuilding Fund, under its 2019 youth promotion In 2019, the WHO country office in Somalia worked to enhance its relations with and visibility among its donors and partners. Improved visibility of what WHO does to improve the health of the people of Somalia and how the Organization is saving lives and preventing diseases has raised WHO’s profile. As a result, the country office has secured important contributions in support of the health response to the recent drought and flood emergencies, through the Central Emergency Response Fund (CERF), as well as a contribution from the Italian development cooperation agency for a hospital rehabilitation project and from the UN Peacebuilding Fund for a mental health project W H O S O M A L I A A N N UAL R E P O RT 2 0 1 9 5 2 health information management system, with pilots in Puntland and Galmudug. With King Salman Humanitarian Aid and Relief Center, WHO foresees undertaking a project alongside the Ministry of Health and Human Services to improve access to life-saving health interventions in Somalia using a PHC approach, with a focus on Banadir region and Somaliland. Finally, together with the Ministry of Health and Human Services, World Bank and other partners, WHO is supporting a review of Somalia’s Essential Package of Health Services. Avenues, arrangements and priorities for potential future cooperation are still being explored with other countries and organizations. WHO Somalia looks forward to continuing to deepen relations and cooperation with donors and partners in 2020 to build strong, long-term relationships based on trust, accountability and effectiveness. (i) providing life-saving and integrated health nutrition services to 85 000 people in the host community and camps for internally displaced people (43 350 males, 41 650 females) and (ii) supporting the provision of emergency obstetric and trauma care services to 17 000 pregnant women and 7200 trauma patients. In its efforts to improve partnerships and communication and build relationships, WHO has re-established positive contact with Canada, European Civil Protection and Humanitarian Aid Operations, Finland, Germany, the Islamic Development Bank, Japan (including the Japan International Cooperation Agency), King Salman Humanitarian Aid and Relief Center (Saudi Arabia), Norway, Office of the US Foreign Disaster Assistance at the United States Agency for International Development, Sweden, Switzerland, the United Kingdom Department for International Aid and the World Bank. Some concrete opportunities for cooperation have already arisen with Sweden, King Salman Humanitarian Aid and Relief Center and the World Bank. For example, WHO will support the efforts of the newly established partnership between the Public Health Agency of Sweden and the Ministry of Health and Human Services to develop a national health institute for Somalia and to strengthen national capacity in laboratory services and surveillance activities across Somalia. WHO will also support a new partnership between the Ministry of Health and Human Services and the Spider Center – an independent centre within Stockholm University that focuses on the digitalization of international development – which aims to develop an integrated W H O S O M A L I A A N N UAL R E P O RT 2 0 1 9 5 3 Visit of the WHO Regional Director for the Eastern Mediterranean and Launch of the UHC Roadmap for Somalia In September 2019, WHO’s Regional Director for the Eastern Mediterranean, Dr Ahmed Al-Mandhari, visited Somalia. One of the main purposes of his visit was to stand in solidarity with the Government of Somalia as it launched its 2019–2023 roadmap to UHC – a major milestone. The UHC roadmap lays out the strategic framework and medium-term goals for the Somali health sector in order to ensure all people and communities receive the More people in Somalia will benefit from UHC, More people in Somalia will be better protected from health emergencies, and More people in Somalia will enjoy better health and well-being. health services they need without suffering financial hardship. The roadmap includes all essential good-quality health services, from health promotion to disease prevention, treatment and rehabilitation, and palliative care. Developed jointly by the Somali Ministry of Health and Human Services, WHO, the UN, civil society organizations, donors and other development partners, the UHC roadmap has three strategic goals: W H O S O M A L I A A N N UAL R E P O RT 2 0 1 9 5 4 Dr Al-Mandhari made his participation in support of this important milestone a priority because he was very aware of the devastating effects suffered by the health system in Somalia as a result of the long- standing emergencies (epidemics, conflict, extreme climatic events), the extensive population displacement, high levels of malnutrition, and the lack of access to hygiene, sanitation and essential health services, all of which have badly affected the health and well-being of the Somali people. During the launch of the 2019–2023 roadmap to UHC, and in recognition of the opportunities this new turning point offers Somalia and the Somali people, WHO, alongside the Somali Government, will bring together humanitarian and development partners and donors to help identify and agree on common goals that could benefit from sufficient, assured and longer-term financial support. —Dr Ahmed Al-Mandhari WHO Regional Director for the Eastern Mediterranean The journey that begins today in Somalia towards UHC will be an opportunity to address weaknesses in policy, leadership, management capacity, human resources for health, supplies, service delivery, and data collection and evaluation. When you strengthen your health systems as part of accelerating progress towards UHC, you will also be able to increase public investment in health and effectively address social and environmental determinants of health through intersectoral action. Social health protection and equity are key considerations in achieving UHC. The international community should now also commit to accelerating progress towards UHC in Somalia by helping rebuild the country’s health systems into more responsive, effective, equitable and resilient health services. W H O S O M A L I A A N N UAL R E P O RT 2 0 1 9 5 5 Business operations 4 offices covered with improved ICT infrastructure and biometric security 4 offices established with improved work environment 7 external missions supported 5 6 Somalia and ensure strong staff cohesion and teamwork as we strive together to effectively deliver WHO’s commitment to achieve better health for the Somali people. New WHO country office for Somalia in Mogadishu For many years, the WHO country office in Somalia operated from a single room, with all staff working within the same area. To overcome this difficulty, the senior management of WHO’s country office, through the WHO Representative, set three objectives in support of staff development and well-being: Driving efficiency For WHO Somalia, our goal is clear: transform the WHO country office into a modern organization that works seamlessly to ensure that measurable improvements are made in health outcomes for all Somali people. Recognizing that this success rests with its staff, the WHO country office takes pride in its rich, multicultural workplace characterized by a high- level of professionalism and diversity of individual backgrounds. In addition, the country office provides an enabling, open and respectful work environment where staff are able to express opinions and concerns, and recognizes and promotes good performance. The office encourages continuous engagement between colleagues through technical meetings, staff planning retreats and other similar activities. In this way, we aim to build positive relations throughout WHO Equip staff to perform their functions at a level of excellence; Support staff development, career paths and learning pathways; Foster a working environment that supports a culture of respect, collaboration, innovation and excellence. In 2019, the WHO country office in Somalia embarked on a substantial transformation effort to integrate the functions of staff, support them with a good and respectful work place and foster a work environment that supports excellence and innovation with the aim of making the whole operation of the country office more effective, responsive and fit for purpose. Building the capacity of the national staff and instituting a culture of measuring, documenting and demonstrating the impact of the work of WHO in Somalia is at the heart of this transformative agenda W H O S O M A L I A A N N UAL R E P O RT 2 0 1 9 5 7 locations, or through a data link. Tokens are used to maintain this secure and remote access. WHO Somalia also set up reliable videoconferencing equipment and infrastructure across its offices, which allows meetings to be held with all staff, regardless of location. The tangible advantages of GPN, VPN and videoconferencing include lower costs to the country office through reduced travel for business and staff training, as well as less time needed for meetings, trainings and projects. Staff development and training In 2019, a number of staff members attended training and workshops held in Somalia, including some which were organized by the WHO Regional Office for the Eastern Mediterranean. The WHO country office recognizes the importance of fostering and cultivating trust, employee motivation and recognition, accountability, and engagement to build more cohesive and collaborative teams, as well as supporting staff development and career progression. These values will remain at the core of the office’s drive and spirit. To align with this framework for fostering a better working environment, the country office embarked on construction of a new country office in 2019, in Mogadishu, which would cater to the needs and requirements of the staff. The office was completed and handed over to WHO in 2019, during a ceremony attended by the WHO Regional Director for the Eastern Mediterranean. Moreover, as the country office expands in order to deliver on the mandate of WHO in Somalia, additional space is being explored. Improved communication infrastructure Communication between WHO Somalia’s suboffices (in Baidoa, Garowe and Hargeisa), liaison office (in Nairobi), WHO Regional Office for the Eastern Mediterranean in Cairo and WHO headquarters in Geneva was a challenge to WHO’s business operations across Somalia because of the lack of a global private network (GPN) and videoconferencing services. As a result, staff had to rely on unreliable telephone and mobile services, which were also costly. To overcome this problem, the WHO country office first rolled out GPN connectivity services in its office in Mogadishu in 2019 and is in the process of deploying the same services to its suboffices, so as to ensure secure communication and access to resources all across the Somalia country offices. In addition, to ensure that staff travelling for work have access to needed WHO services, connectivity has been established through virtual private networks (VPNs), which give access to WHO resources and communication platforms from remote W H O S O M A L I A A N N UAL R E P O RT 2 0 1 9 5 8 they met with the governor and other health authorities. In December 2019, the security team also undertook in-depth pre-planning and coordination activities in preparation for a high-level visit in January 2020 of eight senior managers from WHO headquarters and the Regional Office for the Eastern Mediterranean, led by the late Dr Peter Salama, Executive Director, Universal Health Coverage and Life Course. As well as these activities, the security team continued its regular support of the staff and offices including: arranging missions to Mogadishu city and various field locations across Somalia; providing regular security briefings and advisories to staff; ensuring adequate maintenance of armoured vehicles to ensure safety and compliance on missions; recruiting and retaining security staff across Somalia to effectively support WHO programming; and keeping abreast of evolving security challenges that WHO staff in the country and suboffices face on a daily basis, such as mortar attacks, body-borne improvised explosive devices and improvised explosive device attacks, complex attacks and armed conflict. The security office continues to emphasize the importance of ensuring that communication and personal protective equipment are available to all staff, including helmets and bullet-proof vests. Finally, the security team successfully worked to ensure that the new WHO Somalia suboffice in Garowe met minimum operating security standards and identified armed security services for the compound. After some final improvements, the office will officially be opened in mid-2020. Security management During 2019, the security team of WHO Somalia facilitated a safe and successful visit of several WHO senior managers, including for the WHO Regional Director for the Eastern Mediterranean, Dr Ahmed Al-Mandhari, and Dr Richard Brennan, Regional Emergency Director. During these visits, the security team held strategic security briefings with all mission members, highlighting the security situation in country and the threats and risks. The team also explained the security challenges faced by WHO programmes in Somalia. In addition, the security office supported the movement of WHO Somalia staff and mission members to and from Villa Somalia, the presidential office and residence in Mogadishu, for the launch of the Roadmap for Universal Health Coverage 2019–23 alongside the Prime Minister and Minister of Health of Somalia, health partners and other UN agencies. Members of the mission also visited health facilities in Baidoa, where W H O S O M A L I A A N N UAL R E P O RT 2 0 1 9 5 9 6 0 WHO Somalia would like to express its sincere gratitude to the many donors listed below that have supported its development and humanitarian emergency activities over the 2018–2019 biennium. Generous assistance such as this – in the form of assessed, in-kind and voluntary contributions – helps save lives in Somalia. We appreciate the increasing confidence donors and partners are placing in us to efficiently and effectively carry out our work, as well as lead important health initiatives alongside the Government all across the country. We also thank the health authorities at all levels, communities, health workers, Acknowledgements W H O S O M A L I A A N N UAL R E P O RT 2 0 1 9 6 1 Health Cluster members and the WHO team representing the Organization in every corner of Somalia. We will continue striving to meet the expectations of all stakeholders and to enhance cooperation, complementary endeavours and partnerships in support of achieving UHC in Somalia. Nippon Foundation Norwegian Agency for Development Cooperation Organization of the Petroleum Exporting Countries, Fund for International Development Rotary International Sightsavers The END Fund The Global Fund United Nations Central Emergency Response Fund United Nations Office for the Coordination of Humanitarian Affairs United States Agency for International Development Bill & Melinda Gates Foundation Centers for Disease Control and Prevention, United States of America Department for International Development, United Kingdom of Great Britain and Northern Ireland Gavi, the Vaccine Alliance Gilead Sciences Inc. Global Affairs Canada Government of Germany Government of Japan Islamic Development Bank Merck KGaA National Philanthropic Trust

World Health Organization Somalia www.emro.who.int/countries/somalia/index.html