|
UHUBSO Somaliland National Health Report 200625 January 2006 1. Background The World Health Organisation (WHO), in the glow of optimism surrounding the writing of its constitution, defined health as 'a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity'. Dictionary definitions of health also tend to the absolute. But health is not an absolute. Certainly, the achievement of 'complete' well being is a bold and desirable objective, but a more practical expression of the idea of health is that it represents a state of being which allows effective (and some might add happy) functioning within a given environment, reasonably free of pain, disability or limitation of action. The present aim of the WHO is to make possible the attainment/health for all by all citizens of the world by the year 2000 (5 years ago) of a level of health that will permit them to lead a socially and economically productive life. "Health for All" does not mean an end to disease and disability, or that doctors and nurses will care for everyone. It means that resources for health are evenly distributed and that essential health care is accessible to everyone. It means that health begins at home, in schools, and at the workplace, and that people use better approaches for preventing illness and alleviating unavoidable disease and disability. It means that people recognise that ill health is not inevitable and that they can shape their own lives and the lives of their families, free from the avoidable burden of disease. On the other hand, it has become evident that the capacity to develop is itself depending on health. Health expenditures are cost-effective investment in a nation's human capital, enhancing people's ability to contribute actively to overall economic and social development and enjoy a satisfactory quality of life. Unfortunately, Somaliland's health care system has largely been destroyed as result of war and famine. There are no proper hospitals, and primary care clinics are run by, or rely on, international organisations. In addition to war injuries, the Somaliland's have suffered from famine and widespread diseases. Malaria, tuberculosis, and other infectious diseases are prevalent. Children, women of childbearing age, and the elderly have suffered the consequences of unsafe water, poor nutrition, and a lack of medical services. Due to these factors the infant mortality rate are high, the life expectancy of general population is decreasing, the food supply, per capital total calorie supply (animal and vegetable product) are low and there is scarcity of drinking clean water. 2. The current health care problems In the aftermath of the civil war, the health system, like everything else, collapsed. The following problems are identified as: 1. The lack of medical facilities (in various degrees) 2. The shortage of health professionals. 3. The absence of co-ordination. 4. The shortage of medicines and instruments. 5. The lack of professionalism. 6. The lack of discipline. 7. The lack of repairing and maintenance of the healthcare facilities (hospitals etc). 8. Destruction of the confidence of the community in its health care problems. 9. Mis-use of drugs, due to a lack of control over pharmacists. The two major consequences of these are the destruction of: 1. Mother and childcare 2. Preventive and corrective services. 3. Unregulated private health facilities In response to the health care collapse, private health facilities mushroomed; there are currently many such facilities in most of the cities, with new ones appearing every day. The quality of services varies but mainly very poor. Qualified doctors and nurses run some health clinics, but people with little or no medical training run majority of them. There are no controls in place to regulate these facilities. Personnel operating the clinics do what they like whether their staffs are qualified or not. Prior to the civil war, regulations and codes of practice for medicine, and all personnel had be certified and licensed by a board within the Ministry of Health. Today, former cleaners are performing surgery. 4. Unregulated private pharmacies Pharmacies are another area of the health sector that has proliferated since the outbreak of the civil war. Where stringent rules and licence requirements used to govern the running of pharmacies, today they are "like kiosks". The problem is the same all over Somaliland. There are many pharmacies on the main roads of Hargiesa and other major cities. There are many more in the suburbs and remote villages. Almost all are run by people with little or no training, who dispense all kinds of drugs on request, without doctor's prescriptions. In many cases, the pharmacy owners are happy to both diagnose and prescribe. Many of the drugs on the shelves are either improperly stored or have expired. Many of the drugs are sold from already expired batches, coming in from Italy, India, and Pakistan. Prior to the civil war, the Ministry of Health controlled the flow of drugs into the country, but today, no such controls are in place. There was a programme on Essential Drugs and national drug policies towards the rational use of drugs. The programme seeks to ensure that all people, wherever they may be, are able to obtain the drugs they need at the lowest possible price, that these drugs are safe, effective, and of high quality, and that they are prescribed and used rationally. 5. Lack of hospital and public health laboratory facililities resulted emergence of unregulated private clinical laboratories Even before the current period of social upheaval, diagnostic laboratory facilities in Somaliland were minimal. Today, there are no properly functioning hospital laboratories and no qualified medical laboratory technologists in the country. There are many privately run laboratories in all major cities. The people who run almost all of these laboratories have with a little or no training. They make the diagnosis and prescribe lot of unnecessary drugs without doctors request and advice. Many infectious diseases and serious illness can only be diagnosed reliably by using the clinical laboratory. For example, errors in the diagnosis of malaria have been shown to be particularly high when diagnosis is based on clinical symptoms alone. The laboratory investigations increase the accuracy of disease diagnosis. Misdiagnosis or late diagnosis can lead to: Incorrect treatment with misuse and waste of drugs. Increased morbidity and mortality. Hospitalisation and need for specialist care. Patient dissatisfaction leading to negative responses to future health interventions. Under utilization of health facilities. Lack of confidence and motivation of health personnel. Increased risk to the community from inappropriate disease management and untreated infectious diseases. There is an urgent need to set up clinical microbiology and public health laboratory services in response to: The high prevalence and increasing incidence of infectious diseases. The threat posed by the re-emergence and rapid spread of diseases previously under control or in decline such as tuberculosis, diphtheria, cholera and meningococcal meningitis. The emergence of new pathogens such as HIV and new strains of Vibrio cholerae. The rapid rate at which bacteria pathogens are becoming resistant to commonly available and affordable antimicrobials/antibiotics. The need for reliable microbiological data to develop and validate standard treatments and control interventions, and ensure antimicrobial drugs is purchased appropriately. 6. Prevalent infectious diseases The most common diseases are Tuberculosis (TB), malaria, gastrointestinal diseases (such as diarrhoeal diseases, dysentery, typhoid, and parasite caused infections.), Measles and other vaccine-preventable diseases, acute respiratory tract infections, Meningitis, Hepatitis, intestinal parasitic diseases, Brucellosis and Sexually Transmitted Diseases. The reasons for the disease prevalence's are simple: the collapse of the health and other services, overcrowding, lack of national guidelines, the low level of nutrition of the population (low levels of nutrition causes poor resistance to disease), and the poor quality of the available drugs. The appalling sanitation conditions in the cities are a breeding ground for all sorts of diseases. An alarming new phenomenon in Somaliland is the incidence of infant TB. Normally adults are more likely to contract the disease than infants, but these days we are seeing infants of two months with TB. TB is most common in children under five in Somaliland according to aid agencies. The increase in TB is related to the fact that most carriers remain untreated and mix with the general population, drinking and eating in the same places and using the same utensils. Before the civil war there was a TB hospital where patients were treated, fed, isolated and cured. The Kat chewing carry extra TB risk, Kat chewing sessions usually take place in crowded rooms with doors and windows closed, the Kat reduces desire for food, leaving chewers malnourished and less resistant to infections. 7. Sexually Transmitted Diseases (STD) and HIV/AIDS STDs are highly endemic in underdeveloped countries such as Somaliland where resources for treatment, prevention and education are often unavailable to the general population. Syphilis is highly prevalent in Somaliland and infection with herpes simplex virus is almost universal in Somaliland. Gonorrhoea has a high prevalence in Somaliland. The AIDS pandemic reached the Horn of Africa in the mid-1980s, primarily affecting Ethiopia. As of April 1988, Ethiopia had reported 37 cases of AIDS and Kenya had notified WHO of a total of 2097 cases, whereas Djibouti and Somalia apparently remained free of the disease. Djibouti reported its first case in November 1988, and Somalia reported its first four cases in July 1989. By late December 1991, Ethiopia, Djibouti and Somalia had declared 1534, 104, and 13 cases of AIDS, respectively. The rapid spread of HIV in Djibouti may be a harbinger of future for Somaliland. This possibility is especially likely because of the traditional population movements between Hargeisa and Djibouti. The situation is compounded by the high degree of mobility of prostitutes in Djibouti; the fact that these prostitutes are primarily Ethiopian again emphasizes the potential for regional spread of HIV. According Djibouti Ministry of Health, in the first quarter of 1992, the prevalence of HIV was 51.3% among street prostitutes, 21.7% among bar hostesses, and 11.8% among male attendees at STD clinics. Tuberculosis has been reported to be the most frequent opportunistic infection among AIDS patients from Ethiopia while tuberculosis and chronic diarrhoea are the most common opportunistic infection reported in AIDS patients from Djibouti. A study of TB patients from centres at Hargeisa, Berbera, Boroma and Las Anod in Somaliland carried out in 1999, for example, found prevalence ranging from 9% near the border with Ethiopia and Djibouti to 2% further inland, while another carried out a UK NGO International Cooperation for Development (ICD) in 2000 pregnant women in the same region found only 0.8% are HIV positive. Therefore, there are known cases of AIDS/HIV in Somaliland. The prevalence of HIV/AIDS is at present very low (1%) in Somaliland it is very high in surrounding countries, such as Ethiopia and Djibouti. An increase in the number of returnees in Somaliland from Refugees camps in Ethiopia and Djibouti and those commute regularly from camps in Ethiopia is likely to change the situation in Somaliland unless there is strong support to carefully designed HIV/AIDS prevention and control programmes. Another aspect in which HIV/AIDS could spread is unscreened blood transfusion. Most of the private clinics and hospitals do blood transfusions without screening or proper procedure. If blood transfusion safety is not instituted, it is one of the easiest ways to spread the disease. Another major concern in Somaliland is the high rate of other sexually transmitted diseases. 8. Mis-use and over use of injections in healthcare settings Overuse of injections is common in Somaliland and reuse of injection equipment (syringes or needles that had been used previously on another person and that was reused without sterilisation) in the absence of sterilisation occur in almost one in three injections in Somaliland as reported recently. The combination of injection overuse and unsafe practices results in a major route of transmission for Hepatitis B virus and Hepatitis C virus. Other complications of unsafe injections include infection with HIV, abscesses, septicaemia, malaria, syphilis and viral haemorrhagic fevers. The WHO programme on essential drugs proposed the proportion of prescriptions including at least one injection as a critical indicator of rational drug use. Today, most injections in Somaliland are administered in public facilities with a high number of injections per prescription. Informal private providers also administer the high proportion of injections as well. An urgent need exists to use injections safely and appropriately to prevent healthcare associated infections with HIV, Hepatitis (B & C) and other blood borne-pathogens. There is a need to develop policies for the safe and appropriate use of injections aim to eliminate unnecessary injections and to achieve safe practices. There is also need to establish health education awareness to highlight the risk associated with unsafe injections. There is also need to create proper waste and sharps management to prevent the needle injuries and disease transmission. 9. Collapse of primary health care (PHC) While medical workers struggle to treat, preventative health care has all but disappeared. Even where health services are functioning, they are typically understaffed and ill equipped. A once effective primary health care system completely collapsed in Somaliland over the last decade. With sound PHC you can reduces death from communicable diseases, and get the community involved in preventive measures. Primary health care is essential health care based on practical, scientific and socially acceptable methods and technology. It is made universally accessible to individuals and families in the community through their full participation and at an affordable cost to the community and country. PHC is the central function and main focus of the country's health system and of the social and economic development of the community. It is the first contact of the individual, the family and the community with the national health system, bringing health care as close as possible to where people live and work, and constituting the first element of a continuing health care process. PHC rests on the following eight elements: 1. Education on prevailing health problems and methods of preventing and controlling them. 2. Promotion of food supply and proper nutrition. 3. Adequate supply of safe water and basic sanitation. 4. Maternal and child health care. 5. Immunization against the major infectious diseases. 6. Prevention and control of locally endemic diseases. 7. Appropriate treatment of common diseases and injuries. 8. Provision of essential drugs. 10. Present national health requirements: Human resources; the return of qualified staff (doctors, nurses, midwives, pharmacies, radiologists, operation theatre staff, anaesthelogists & medical laboratory technologists) after training or retraining. The compilation of an inventory of resources and facilities. Re-education; to rekindle the confidence of the people in their health care advisers. The provision of technical advice. Financial and technical contribution. Encouragement of healthy life-styles; cut out expenditure on (e.g.) khat, tobacco, pot and divert the money to more productive areas. 11. The International community should be involved in: 1. The provision of effective assistance, particularly with the identification of needs, and the provision of: Expertise Basic supplies and equipment Technical, drug policies and health regulation guidance 2. The establishment of an up-to-date health information system. 12.Recommendations The solution of health care problems and challenging nature of these tasks depends on the Somaliland people and their contribution. The principle recommendations is to create a structure and system of government, to ensure that communities are involved and committed to the improvement of the health of the people, security and the need for an inventory resources and facilities. Somaliland Community Development (UHUBSO) Contact@uhubso.com WWW.UHUBSO.COM UK registered charity no: 1112216. |
