HEALTH SYSTEMS STRENGTHENING IN FRAGILE CONTEXT

Progress and learning. Action Against Hunger Somalia.

Presented at Health cluster meeting 14th

October 2021.

INTRODUCTION• Action Against Hunger is one of the major

humanitarian actors present in Somalia since 1992.

• During our 28 years presence in Somalia, Action Against Hunger has provided lifesaving Nutrition; Health; Water, Sanitation & Hygiene; Food security and Livelihoodssupport to the most vulnerable population

• Current field operations are supported through five bases in Mogadishu, Garowe(Puntland), Eyl (Puntland), Elbarde (Bakool) and Xuddur (Bakool); besides two additional sub-offices have been opened in Wajid(Bakool) and Yeed (Bakool) to expand the technical outreach capacity in the region.

• Action Against Hunger also leads two Health consortia – Caafimaad Plus funded by ECHO and EPHS project Lot 1 (formerly SHINE supply

Banadir/Lower-Shabelle

l Kahdal Hodanl Abdiazizl Afgoye

Bakool

XudurWajidElbardeRabdhure

Nugaal

l Eyll Burtinle

CAAFIMAAD PLUS CONSORTIUM MAP

HEALTH SITUATION

1210 11901080

939820 732

1990 1995 2000 2005 2010 2015 2019

MATERNAL MORTALITY RATIO (PER 100,000 LIVE BIRTH)

UHC Index = 22 (2019)

Low

Res

ourc

e (H

SSIn

put)

General Service Availability Index(infrastructure, Health Workforce, Service utilization)

17.3

Health facility density per 10,000 population(target=2),

0.76

Number of outpatient visits per person per year (Target=5),

0.23

Health workforce density per 10,000 population (Target 23)

4.28

Essential Medicine Availability(Urban 19% vs Rural 8%)

15%

Per capita public expenditure on health (per person per year) - Target US$60-86

US$10–12

Health Expenditure on government budget (target15%)

<2%

Indicators available to monitor health- related SDG 38%

Health Systems Governance index(target 10) 7

IHR Core Capacity (Score 1-2) Limited

ACUTE MALNUTRITION JULY 2020 - JUNE 2021

849,900

the number of 6-59 months children acutely malnourished

INNEEDOFTREATMENT

Severe Acute Malnutrition (SAM)

143,400

Moderate Acute Malnutrition (MAM)

706,500

Global Acute Malnutrition (GAM)

849,900

HEALTH SYSTEM CHALLENGES • Weak health system & institutional

capacity. • Non –functional District Health

Management Team (DHMTs) • DHMTs were nominated and

endorsed by the FMOH in 2014 under the Joint Health & Nutrition Program (JHNP) project but not functional

• Fragmented donor support • Poor data quality – No efforts to audit

quality of data (from registers, Monthly HMIS Excel report and the DHIS2 data.

• Non-utilization of data for decision making.

• Services provided by NGOs/private sector.

• Lack of coordination meetings at the district level.

ACF SUPPORT TO HEALTH SYSTEMS• Through SHINE Supply and other projects with

an objective to develop government stewardship capacities to enhance service delivery

• Operationalization of district health management team

ü Seconding two staff to provide TAü Development of JDs for DHMTsü Development of TORs with clear

deliverablesü Equipped DHMT offices.

• Capacity building of DHMTs and Health facility staff.

• Formation of Health facility committees. • Set up Monthly coordination meetings at

different levels( HF Committee, HF staff, HF in charges & DHMTs)

• Initiated joint supportive supervision• Established online JSSV platform to enable

visibility up to regional and national level. • Monthly data quality audits with District HMIS

Officers to inform decision making and programming.

Photo: Waberi District Health Officer at her office

RESULT – ACCESS AND UTILIZATION OF SERVICES

2017 2018 2019 2020FP Services 136 94 409 768

0100200300400500600700800900

# O

f Ben

efic

iarie

s

Family Planning Services Utilization Trend (Source: DHIS2)

• Increased access and utilization of services i.e.Penta 3, Deliveries, Family planning

52836098

82839501

02000400060008000

10000

2017 2018 2019 2020

No.

of i

mm

uniz

ed

Year

Penta 3 Service utilization trendSource: DHIS 2

2281

35233959 4108

0

500

1000

1500

2000

2500

3000

3500

4000

4500

2017 2018 2019 2020

No.

of d

eliv

erie

s

Year

Delivery service utilization trend Source:DHIS2

RESULTS - CUSTOMER SATISFACTION.

5% 6% 4%

85%

Preference of seeking health services

Don't know No preference Prefer a different facility Prefer same facility

44%

43%

11% 2%

Waiting time to receive services at the HF

Less than 15 Minutes 15-30 minutes 30-1 hour More than 1 hour

51%

43%

3% 2% 1% 0%

Good Excellent Fair Poor VeryPoor

Don’t know

How satisfied are you with the services you received today?

We assessed customer satisfaction levels through Customer satisfaction survey and found services provided at SHINE health facilities meet the quality expectations of the clients.

RESULT - IMPROVED DATA QUALITY

29 29 29

0

5

10

15

20

25

30

35

Reportedfigures in

Nov

Figures inDHIS2

HMIS Data

Output Indicator1.2:# of womenreceiving moderncontraceptivemethods (totaland additionalusers)

17

7

17

02468

1012141618

Reportdfigures in

August

Figures inDHIS2

HMIS Data

# of womenreceiving moderncontraceptivemethods (totaland additionalusers)

August 2019 Data Quality Audits At Elgab Health Center, Banadir - Somalia.

November 2019 Data Quality Audits At Elgab Health Center, Banadir - Somalia.

• 100% concordance after DQA• Improved quality of data for decision

making

CONT.

55 55 55

0

10

20

30

40

50

60

Reportedfigures in

Nov

Figures inDHIS2

HMIS Data

Output Indicator1.3:# of womendelivering withthe help of askilled birthattendant at ahealth facility

August 2019 Data Quality Audits At Elgab Health Center, Banadir - Somalia.

November 2019 Data Quality Audits At Elgab Health Center, Banadir - Somalia.

49 49

39

0

10

20

30

40

50

60

Reportdfigures in

August

Figures inDHIS2

HMIS Data

# of womendelivering withthe help of askilled birthattendant at ahealth facility

100% concordance in data

CONT.

August 2019 Data Quality Audits At Elgab Health Center, Banadir - Somalia.

November 2019 Data Quality Audits At Elgab Health Center, Banadir - Somalia.

100% concordance in data from different reporting platforms.

DHIS HMIS Project reportingAug-19 627 817 825

627

817 825

0100200300400500600700800900

Repo

rted

figu

res

Reporting platform

OPD data

DHIS HMIS Projectreporting

Nov-19 1006 1006 1006

1006 1006 1006

0

200

400

600

800

1000

1200

Repo

rted

figu

res

Reporting Platform

OPD data

COVID-19 RESPONSE• Establishment internal taskforce for proper coordination,• Provided prompt support to Martini hospital:

• 34 FMOH national COVID-19 staff supported in Martini hospital (March2020 to October 2020)

• Construction of secondary COVID-19 center in Forlanini hospital,• Provided referral ambulances with the support of Aamin Ambulances,

• Capacity building of frontline health :• 300 CHWs on RCCE and IPC,• 214 frontline health workers trained on IPC, case management,

• 22 health facilities were provided with PPEs, hand sanitizers,temporary COVID-19 screening tents, other preventive measures,etc,• Mobilization of funds internally and externally. E.g.

• GFFO, UNICEF HPD, CPD, RRF, Internal Fund,

COVID-19 VACCINATION • Vaccination sites supported by ACF through respective MOH:

• 13 health facilities in 10 districts Bandar Region were selected to be vaccination sites,

• 3 health facilities (Elberde RHC, Yeed HC and Wajid HC)• Afgoye hospital,

• A total of 11,952 (6350 M and 5602 F) successfully completed 2 shots of COVID-19 vaccination in all supported health facilities. • COVID-19 awareness session conducted both at the health facility

and community levels reached: • 78,482 (37,907 M and 40,575 F),

OTHER ACHIEVEMENTS • ACF Somalia operationalized DHMTs in Banadir region(12

districts) and Southwest state(5 Districts)• Capacitated 89 regional and district health management teams

across 6 regions in Somalia including consortium partners on 2004 WHO contextualized DHMT training package.• ACF successfully set up and equipped DHMT offices.• Monthly and Joint quarterly supportive supervision exercises

conducted • Data quality audits at health facility level Vs DHIS2.• DHMTs active involvement in recruitment and day-to-day

activities in their respective districts.

MONITORING

• Quarterly joint review meetings

• Joint supportive supervision conducted with MOH R/DHMTs.

• Adhoc Spot checks. • Data quality audits on

monthly basis. • Customer satisfaction

surveys

Photo: Joint JSSV With R/DHMTs At Waaberi Health Center, Banadir - Somalia.

CHALLENGES • Fragile health system existing in the country. The DHMTs are not

at liberty to visit some facilities managed by other stakeholders including private entities. • Inadequate resources allocated to full Health system strengthening •Health facility needs major rehabilitation- limited budget

to support.• Insecurity and access challenges- delay in delivery of

supplies by air and high cost of transportation.

LESSONS LEARNT • HSS approach improved utilization of services and improved data

for decision making• Joint supportive supervision visits created accountability and

follow up on action plans. • Putting the government in the driving seat enables more

sustainability, ownership, and greater value for money in service delivery. • The involvement of DHMTs in sensitization and community

awareness activities leads to better demand and uptake of services i.e. increase of modern birth spacing uptake with the availability of commodity at the health facilities.

SHARING & USE THE LEARNING• Documentation of lessons learnt through case studies and

success stories. https://shinesupply.org/news/shine-supply-reinstating-somalia-district-health-management-team-operationalization/.

• Quarterly review meetings with donor and other stakeholders• Monthly Consortium Technical working group meetings• Health & nutrition cluster meetings are to share learning across

the relevant sectors.• The DHOs were encouraged to share their learning from SHINE

with colleagues in non-SHINE supported Districts across the Banadir region.

Photo: Data Quality Audits During the Joint JSSV With R/DHMTs At WaaberiHealth Center, Banadir - Somalia.

Photo: Joint Data Quality Audits At Elgab Health Center, Banadir - Somalia.

PHOTOSACF hands over COVID-19 supplies to FMOH

ACF hands over vehicles to FMOH for COVID-19 coordination and response

ACF Regional Director and Country Director for Somalia dispatching COVID-19 supplies from Nairobi to Mogadishu.

Beneficiaries at the waiting areas in Afgoye hospital practicing social distancing.

Elberde District Health Officer Taking the first shot of AstraZeneca vaccine in Elberde –Bakool Region.

Health Care Worker Preparing COVID-19 Vaccine for a beneficiary in Afgoye Hospital.

Ribbon Cut and Opening Ceremony for COVID-19 Referral Hospital in Forlanini

THANK YOU

“I am proud of what we have been able to achieve as a district team in the last year. I have been given a voice to raise issues on the gaps and challenges of the health facilities I manage. When structures are put in place, the systems work for the good of every person, for facility staff, management levels or even the beneficiaries”, Hawa Waberi District Health Officer