Somaliland has made impressive gains in strengthening its health services, but substantial challenges remain for the unrecognised nation. Sharmila Devi reports from the capital Hargeisa

FGM, including the most severe form, is widespread in SomalilandSomaliland—a self-declared republic that broke away from Somalia in 1991 and whose independence remains unrecognised by the world—has made great strides since civil war destroyed much of the region from where more than 500 000 people fled in the late 1980s.

Thanks to remittances from Somali- landers abroad and foreign aid, much of the capital Hargeisa has been rebuilt and the rubble removed while the trappings of statehood, including health services, are slowly emerging. But the challenges remain steep in a region that has some of Africa’s highest maternal and child mortality rates.

Multilateral agencies, including WHO, will not deal with Somaliland as an independent entity but as one of three regions of Somalia—the others are Puntland and Central-South Somalia, which includes Mogadishu (figure).

Healthy life expectancy is 45 years compared with a regional average of 58 years, according to 2012 WHO data for Somalia as a whole. Somaliland ranks as 161 out of 163 least developed countries in the world.

Edna Adan, a former foreign minister of Somaliland who founded a university hospital that bears her name in Hargeisa, is internationally credited with much of the energy behind the young state’s progress in health. But she is the first to acknowledge the many remaining obstacles. The challenges range from the quest for political recognition and the greater budgetary support that might accompany it, the urban–rural divide, the need for greater professionalisation, to combating mental illness, the use of khat, and female genital mutilation (FGM). “We now have security and stability with no warlords and the people in government have set up the physical structures of health and education”, she

told The Lancet. “But we need help to train our health professionals, so we can acquire the knowledge to assist people.”

Adan returned to Hargeisa in June, 1991, soon after the declaration of independence. The city had suffered aerial bombardment by the Somalian dictator Mohamed Siad Barre. Mass graves continue to be discovered in Somaliland. “What I saw haunts me to this day. Hargeisa was a ghost town full of war debris and land mines”, said Adan, who has been spoken about as a possible Nobel prize nominee for her work in health and campaigning against FGM.

“‘Somaliland has put in place a formidable health service since it separated from Somalia
24 years ago…’”

edna1She was one of the first, and remains one of the few, Somaliland women to drive in this Muslim and socially conservative country where all women wear head scarves and long robes. Her local fame was palpable when she drove The Lancet’s correspondent through the slow traffic of Hargeisa as people shouted “auntie” in recognition.

“Somaliland has put in place a formidable health service since it separated from Somalia 24 years ago when the people and the government had the task of rebuilding the health service. Today, there is a public hospital in every region and there are mother and child centres throughout Somaliland. It’s a long way from ideal but there is continuing momentum”, said Adan.

Health cooperation among Somalia’s three “zones”, including Somaliland, according to UN terminology, was active and working, said Humayun Rizwan, the acting WHO representative for Somalia. A health advisory board

with representatives from all three zones met regularly to set priorities and allocate resources according to need, he said. “I’ve been here for 6 years and I can say in the health sector, there have been improvements”, he said. “We used to have meetings when the representatives would sit in three separate rooms but now they all talk to each other.”

But political tensions meant, for example, that training for health workers could not be done in one of the three zones but had to be done in a neutral space, such as Kampala or Nairobi, he said.

WHO’s working population figure for Somaliland is about 3·4 million and some 70% are estimated to be under the age of 30 years. Barely 40% of the population have access to public health care, Rizwan said. Many people used traditional healers or consulted pharmacists, many of whom were not qualified to provide medical services or prescribe medicines.

The health ministries of the three zones are working closely together to increase the number of female community health workers (FCHWs), or marwo caafimaad in Somali. Several hundred women have been trained

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