Author: Mohamedali, F.; Schwarz, R.; Schlueter, P.; Guild, S.; Bertrand, W. E.; Development Solutions for Africa
UNICEF plays a central role in the provision of primary health care in Somalia. In the past 5 years, UNICEF has shifted its focus from service delivery to the provision of technical assistance, supplies and other resources. Major partners are the Somaliland Ministry of Health and Labour (MOH&L) in the North West Zone, the Puntland Ministry of Social Affairs (MOSA) in the North East Zone, and international and national non-governmental organizations (NGOs) in the South and Central Zone. The transition from emergency to development in the NW and the NE has offered new opportunities to gradually shift the overall responsibility of provision of health care to the administrations in place. UNICEF's program in Somalia was last evaluated in 1995. USAID, the major funding agency for UNICEF/Somalia, requested an external evaluation of the program as a part of the 1999-2000 contract. In January 2001, Development Solutions for Africa was contracted by UNICEF Somalia to perform this evaluation.
Purpose / Objective
The specific objectives are:
- To determine the extent to which UNICEF Somalia health and nutrition activities met planned targets, coverage and strategies agreed and finalized by USAID
- To determine, using data available and collected during the evaluation exercise, the extent to which UNICEF activities have adequately addressed the health and nutrition needs of Somali children and women in the target areas
- To review UNICEF Somalia PHC and MCH management, and PHC guidelines and standards, and give recommendations on improvements or changes as necessary
- To meet with NGO partners involved in MCH management and PHC activities to identify issues and problems that need to be addressed in order to improve health programming in Somalia
- To identify the lessons that can be drawn from the evaluation and recommend how to incorporate these lessons in future health program design and implementation
- To recommend areas to be changed and/or strengthened in UNICEF health interventions (including EPI) in Somalia
- To recommend new areas or methods of intervention in the health and nutrition sectors, especially for the emergency areas of the country
- To facilitate at the end of the consultancy, a meeting to review, and revise as necessary, UNICEF Somalia's planning and interventions in Somalia
The evaluation was conducted in phases. The first phase consisted of a review of documents supplied by UNICEF's Monitoring and Evaluation Officer to identify each agency with a role in the execution of joint programs managed with UNICEF's support. Documents were also collected from the partner agencies.
Due to time constraints and issues of security, the choice of areas for the field visits was not a random selection. Therefore, field findings are used to illustrate examples of planning, implementation, UNICEF-partner relationship and the relevance of UNICEF's Health and Nutrition Programme.
Health activities in the field were observed and assessed by visiting health facilities managed by international NGOs, local NGOs, the administration, activities of the mobile EPI teams and the Community Based Organizations. Questionnaires were administered in all the static health facilities, and both group and one-to-one discussions were held with staff.
Key Findings and Conclusions
UNICEF is the main supplier of essential drugs and supplies to the providers of health services in Somalia. While there have been problems with UNICEF's Essential Drug Kit System, the kits still seem to be the most appropriate option. UNICEF has worked hard to resolve many of the problems and, during this evaluation, all facilities visited had received drug kits within the previous two months, and no expired drugs were found.
A major achievement has been the establishment of a regular supply of vaccines for the Expanded Programme for Immunization (EPI). The strategy of supporting partner agencies with cold chain equipment, supplies, vaccines and training has proven to be successful in achieving high immunization rates in a very difficult setting. The combination of static and mobile sites is important for providing equity in vaccine access to nomads and dispersed populations as well as urban populations. "Piggy-backing" Vitamin A supplementation to EPI has resulted in dramatic improvements in the coverage of this micronutrient. UNICEF has proven that the private sector and local NGOs can provide immunizations, and local authorities can be responsible for logistics. Some cold chain and other technical problems were noted during the evaluation, and it was also noted that EPI guidelines were not available in the field. Guidelines should be distributed, translated when necessary, and referred to during training and supervisory visits.
The National Immunization Days for the Eradication of Polio (NIDs) program is both an opportunity and a threat to on-going EPI. A notable achievement is the very high immunization coverage in the SCZ. However, partners have complained that NIDs has created problems by offering high rates of remuneration to personnel who normally conduct EPI for free and by completing plans without consultation with local partners. Planning for NIDs needs to involve all partners and should be on-going throughout the year so that remuneration, logistics, reporting, etc. can be integrated with, and improve, on-going programs.
UNICEF's Nutrition and Reproductive Health Programmes have been less successful. It is recommended that UNICEF reduce expenditure of scarce resources on ineffective interventions in these areas and focus on EPI, Essential Drugs, promotion of breastfeeding and community-based improvement of nutritional status, the distribution of micronutrients, training and capacity building.
Somali communities have a strong tradition and their own way of managing household and group resources. UNICEF's future programs should include the basic component of community mobilization and capacity building. This component should also be part of other partner agreements and monitored by UNICEF field personnel.
Cost-sharing has been introduced in most of the health facilities in the NW and NE, and in parts of the SCZ. A major shortcoming of these efforts has been the failure to follow up on the recommendations from the report on Health Financing and the Strategic Plan for the Health Sector in Somalia.
UNICEF has neither the mandate nor resources required to manage and assist implementing agencies to deliver a full range of basic health services to the entire population in each Zone of Somalia. UNICEF is already trying to accomplish too much with too few resources, and needs to refocus and prioritize its interventions. While the health policy and strategic plan for Somalia are well formulated, the strategies to achieve program objectives need to be carefully and explicitly adapted to the organizational and institutional contexts between and within each Zone. Health sector reform strategies and operational plans need to be more precisely formulated in terms of actual capacity and resources available. Priorities and targets need to be formulated separately for each Zone.
The problems of co-ordinating and supporting a large number of INGOs, local NGOs and different administrations in each Zone are an extremely complex task. More attention and resources should be given to the decentralization of programs, Zonal level co-ordination, increased supervision of activities and capacity-building. Increased emphasis on coordination, planning meetings in the Zones and a reduction of the field staff time in Nairobi are particularly important as the capacity-building of local administration and Somali-based organizations is given a higher program priority.
The private sector (including pharmacies) has been and will continue to be the major provider of health services. Policy and plans need to address the role and responsibilities of the private sector in the provision of safe, low cost drugs; accurate information to clients; and both curative and preventive services. They should address specific measures to protect the public from abuse, fraud and excessive costs, and how the public sector resources can be used to improve the services and products provided through private practitioners and suppliers of pharmaceuticals. Initiatives that could be taken to expand the scope of health sector development to the private sector include: education and training; assisting authorities to develop guidelines for registration and certification; assisting Somali health workers to create effective professional associations; the "purchase" of services from established private services.
UNICEF and other donors also need to expand the scope of their institutional partners to include universities and other research and training institutions in developed and developing countries. This is particularly critical to the long-term success of capacity-building initiatives, including the establishment of Health Training Centers. The experience of the past decade clearly reveals that the use of a highly collaborative approach among NGOs whose primary concern and skills are emergency interventions and the delivery of basic health services is complex, slow and costly. Another level of partnership is needed to move forward quickly on the development of administrative structures and educational institutions for the health sector.
To support the development of a sustainable health care system, UNICEF should increase its promotion of stakeholder participation at all levels. In areas of stability like the NW and the NE, UNICEF's role should be to expand and improve the quality of stakeholder participation in planning, implementation and monitoring of health-related services.
The general direction of administrative reform and development in Somalia appears to be towards the establishment of regional and zonal authorities similar to those functioning in the N.W. and N.E. Zones (Somaliland and Puntland). Regardless of what happens in terms of the re-establishment of a centralized Somali Authority and its international recognition as a Nation-State, the political landscape will include strong Zonal administrations. This pattern is appropriate to Somali society, which has always functioned on a tribal and clan basis. In view of this, the donor community and the implementing agencies should give high priority to building the capacity of Zonal, regional and district health authorities to manage and deliver health services. As part of this, increased attention to private sector initiatives, additional external collaboration, local participation and community control is recommended.
At this time, the training of Somali health workers, including local professionals, should be done in-country, and should:
- Expand short-term training of local administrative, professional and auxiliary staff
- Support the operation of existing, and the establishment of new Zonal and Regional Health Training Centers, and the training of a cadre of teachers and administrators to work in them
- Expand training programs to include administration, management and health planning, and budgeting
- Support the production of training and learning materials for managers, health professionals and auxiliary staff
- Explore and identify opportunities and mechanisms to recruit Somali health professionals living outside the country. Expatriate Somalis should be considered as essential to the staffing of health training institutions in the Zones
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Health - Nutrition