Somaliland Cyberspace

Children's situation Analysis in Somaliland
Health and Nutrition

Source: World Health Organization
Embro Programme
2002/2003

By: Dr. Abdirahman Abdillahi Mohamed

Sub: Report on the Literature review.
Hargeisa

Background;

After the ratifications of the children's rights by the Government of Somaliland, the concerned ministries and International agencies decided to carry out a Children's situational analysis survey, to be a baseline for Future planning and strategies towards children in Somaliland.

The first step for situation analysis is Literature review, so a consultant and a core team from regional team leaders started the literature review.

Many documents were collected from various ministries, international NGOs, Local NGOs and United Nations organizations.

Health and Nutrition were included among these documents collected. Around 30 different documents were selected for the review of Health situation analysis.

Introduction:

The major purpose of reviewing available health literature was to get an idea about the current situation of the children's health in the country. Going in line with the terms of reference of the research on children's situation in Somaliland, we were putting our insight in the major crosscutting questions and basic health oriented questions. We departed from the question of, what the problems, and their causes, of children stated in the documents? What solutions are recommended for the problems, if there are any? How the document is relevant to reflect the actual situation of children in Somaliland, if at all? How the document is helpful in current children's situation, if it is not out-dated? What is the impact of Poor nutrition, communicable diseases and other diseases on children's Health? And so on. We reviewed all the appropriate documents that we thought has written some significant issues about the children's situation, focusing on areas of Health, Nutrition, psychosocial aspects and general well being of children.

The documents were divided into (see references):

a. Health policies developed by the government
b. Studies carried out during the last several years.
c. Health reports from various organizations
d. Strategic and contingency Health plans.
e. Multi-sectoral references

Findings from the literature Review for Health:
Health is Defined as: "The state of physical, Mental and Social well being of an individual" (WHO, 1998).

So a healthy child (a child is any individual less than 18 years of age, CRC,1989; African Charter on the Rights and welfare of the child,1991) is the one who is physically fit, psychologically Normal and socially stable. The meaning of fitness, Normality and stability can be more subjective and may have different interpretations in different people, but we mean that: A physically fit child is a child who has no disabilities and free from disease, While psychologically Normal child is the one who do not have any kind of mental problems Or psychic disorders, Whereas Socially stable child is the one who can get all his/her social needs such as: caring family, education, health services and other basic needs.

Article 17, section 1.1 of the constitution of Somaliland is read as:

"In order to fulfill a policy of promoting public health, the state shall have the duty to meet the country's needs for equipment to combat communicable diseases, the provision of free medicines, and the care of the public welfare".

Besides that, the mission statement of the policy of the ministry of health and Labour stated as: "to attain the highest possible health status and social well-being of all Somalilanders", and its mission statement says: " To create an enabling environment for the provision of affordable, quality, equitable access and sustainable health care in Somaliland" (, MOH &L, 1998)

But, from the findings of the literature review we have identified some problems facing the children in Somaliland, Some opportunities and future prospects and some significant challenges.

Most of the documents were several years old that they do not reflect the current situation of children in the Somaliland.

Major surveys, which has been carried out by several UN agencies and INGOs were carried out years before, so in the fasting changing situation of the country they are not applicable in many aspects.

Major health problems documented in the literature review included:

a. Sexually transmitted diseases including HIV/AIDS.

Several documents were focusing this issue. It has been claimed that the prevalence of HIV/AIDS in the country is relatively low <1% (UNICEF, 1999) While among study TB cases the Prevalence of HIV/AIDS was up to 8.8% in Some regions(WHO, 2000). The prevalence of other sexually transmitted disease was as high as 30% (Gillian Duffy, 1999).

There is a danger of deterioration of the situation of HIV/AIDS in the country and this high prevalence of STIs can be a good indicator of this possible threat, in addition to the neighbouring countries in which the disease is hyper-endemic.

It is well know that children are, usually, adversely affected by this pandemic scourge, not only by the fact that most of the HIV positive mothers usually infect their children, but also the painful aftermath of losing a parent.

The widespread practice of harmful traditional surgical operations, which are usually performed during the childhood such as: Tonsillectomy, Uvulectomy, tooth extraction, bleeding, Sub-lingual vasectomy, and Adenoidectomy are increasing the danger of HIV/AIDS in the country, since un-sterilized sharpened materials are used in all these operations.

Gaps identified in this topic:

* There wasn't neither qualitative nor quantitative study focused the issue of children, in particular as far as STIs are concerned.

* The knowledge and awareness of STIs among 975 youth interviewed in a study was very poor; most of them even refused to respond the questions on the topic (UNICEF/MOHL, 1999)

- No statistics are available for children orphaned by AIDS.
- There is no policy set for the matter in General and for children in particular.

b. Neonatal mortality rate (NMR), Infant mortality rate (IMR) and Child Mortality rates (CMR)

Neonatal mortality rate, Infant mortality rate and Child mortality rates are defined as: the proportions of children died under one month, under one year and under five years of age respectively, in every 1000 live births.

Child mortality rate in Somaliland is among the highest in the world, it is documented that child mortality rate (CMR) is Around 328/1000 live births, IMR (infant mortality rate) is 113/1000 and NMR (Neonatal mortality rate) is 28/1000 (, WHO office for Somalia, 1999)

Over one quarter of all under-five deaths occur in the first week of life due to complication of Pregnancy and delivery ( Unicef Somalia, 1999)

The very high maternal mortality rate in the country which is estimated to be around 1600/100 000, also contribute to the sufferings of the new-borns in addition to yearly 110 000 Pregnancies with complications, Illnesses or permanent disability for the mother and/or the child (Noreen Prendiville, 1999)

What factors contribute to the high mortality and morbidity rates of children?

It is not possible to list all possible contributors of the children's mortality and morbidity, and many may not be even known but, in short, we can hereby highlight the following health problems affecting children (given that socio-economic factors also play great roles) in the literature reviewed such as:

a. Immunization coverage against the six childhood illnesses is very low through out the country, and estimated to be less than 20% ( Unicef, May 1998). Apparently the lowest immunization coverage is found in the Nomadic settlements, followed by Rural and Urban.

Only 9.3% of children had immunization cards (Unicef Somalia 2001) but it is found that 69% of children aged 12-23 months received BCG vaccination, whereas only 35% of children had 3rd dose of DPT.

Recurrent outbreaks of measles in almost all the regions of the country is a good indicator of low immunization coverage, and the situation is more severe in the Nomadic and rural areas.

b. According to the Muti-indicator Cluster survey (MICS) conducted by Unicef in the year 2000, Only 39% of children aged 6-59 months received the high dose VitaminA supplement and this could lead, theoretically, high prevalence of Vitamin A deficiency disorders, although such deficiencies are not reported in the health settings.

c. Breast feeding practices are not satisfactory: as mentioned in the Multi-indicator cluster survey (MICS) of the 2000 conducted Jointly by UNICEF & MOH&L, only 20% of children aged less than 4 months were exclusively breast-fed.

d. Unavailable safe drinking water in more than 70% of Households (UNICEF/MOHL, 2000)

Sufficient and safe drinking water is the main cornerstone of health for every person in general, and children in particular; water scarcity usually results in poor sanitation and hygiene measures and thus probable out-breaks of certain communicable diseases.

Water shortage is a common phenomenon in the Somaliland, by the fact that the highest annual rainfall ever recorded was 836mm in 1986 and the lowest was 156mm in 1965 (Hargeisa water agency, 1996)

Availability of water in the urban settlements is also very low. It is estimated that the capital city of Hargeisa gets of its daily water requirements (ibid, 1996)

In this situation of scarce safe and clean water, it is no wonder that diarrhoeal diseases ranked number One among the endemic and epidemic communicable diseases, including Cholera.

e. Female genital mutilation (FGM) is widely practiced in the country with severe subsequent complications for young girls and women from the day the operation took place to the rest of their lives. 99% of the girls were circumcised and 94% of them had the worst type, which is the pharonic circumcision (WHO, 1999).

In pharonic circumcision the whole clitoris, the labia minor and part of labia major are removed and then the remaining parts are stitched, leaving a passage for urine and menstruation which is mostly so narrow that a stick of match hardly passes through.

Girls as young as 3 years of age were found to be circumcised, but most of the girls were circumcised between the ages of 5-10 years. The most common complications reported are: Severe haemorrhage during the operation, infection including septicaemia that sometimes results in death of the young girls, urinary and menstruation retention.

And later there is a severe complication during the child delivering that mostly endangers (and sometimes kills) either the mother or the child or both (WHO,1999)

According to the surveys conducted by WHO and Unicef, most of the people, wrongly, believe that the practice has religious basis, so they are against eradicating this harmful tradition; However, nowadays many people accepted to change the typology of the circumcision from pharonic to Sunne type.

Gaps identified in this burning issue were:

- Lack of clear policy from the side of the government in regard to FGM.
- Lack of high level advocacy to fight against this harmful practice
- Lack of clear plans to tackle with the problem
- Role of the mothers seemed neglected when the issue is addressed in several reports.
- Religious leaders have no clear stand towards FGM
- The documents reviewed on the subject matter were mostly KABP Survey, but there were no action oriented one.

f. Lack of child spacing:

The fertility rate of women in Somaliland is as high as 7.9 (WHO, 1999). Given that there is no family planning and the low percentage of breast feeding mothers after 4 months of delivery, it is clear that there is no child spacing procedures and this will have negative health impact both to the concerned mothers and their children.

g. Early marriage.

Some studies show that 18% of women interviewed told that they give their first child before the age of 18 years(Unicef 2000). Early marriage usually results in adverse effects on the young mothers and their new- born, especially during delivery. Complicated and obstructed labour is very common among the young girls. Early age also predisposes some genetic disorders to the offsprings such as Down's syndrome.

What are the most common serious diseases among children?

The most prevalent diseases that are responsible both the high morbidity and mortality rates of Children are:

1. Diarrhoeal diseases:

Like all other developing countries in General and the least developed of the under developed countries in particular, Children's diarrhoeal diseases remains one of the leading killer diseases.

UN agencies mandated to children's development and supported estimated that, 19% of the 12 million children who die every year in the developing countries, is due to Diarrhoeas.

In the multi-indicator survey conducted in Somaliland in the 2000, 17% of children have had diarrhoea two weeks prior to the survey.

In this MICS only 31% of household have been identified having safe drinking water, so the main underlying cause of high prevalence of Diarrhoea could be due to poor sanitation and unsafe drinking water.

Cholera epidemics have occurred several times since 1990.

The major etiologic microbes of diarrhoea in children are not well documented, but it is believed that it mainly caused by entero-viruses.

Intestinal parasites are also very common causative agents of diarrhoea in children. Giardiasis, Entrobmius Vermicularis and Ascaris Lumbricoides are the most common intestinal parasites among the children although reliable and recorded statistics are not available.

2. Tuberculosis:

Tuberculosis is believed to be the most prevalent disease among the communicable diseases in this country. Unfortunately there is no statistics available, in regard to neither the morbidity nor the mortality of tuberculosis in children.

The drugs used in all the seven (7) treatment centres in the country are donated by WHO, and there isn't any paediatric drugs supplied; there are no even clear guidelines for the diagnosis or treatment of the disease for children.

So, It seems that there is no proper management of the most serious and prevalent disease in the country as far as children are concerned.

3. Measles.

Generally, 7% of Childhood deaths in the developing countries is due to Measles, In Somaliland the low immunization coverage, less than 17% among the 12 months age groups (UNICEF, 2000), epidemics of measles are reported now and then, not only in the nomadic and rural areas where lowest coverage are expected, but also in some urban cities. It worthies-to- mention that the high mortality and morbidity rates of this childhood illness is well known.

4. Malaria.

Malaria is one of leading diseases as far as morbidity and mortality is concerned, but accurate statistics in regard to malaria cases and deaths in children are not available. The disease is hypo- endemic in the country, but epidemics are very common and all the regions and districts of the country are considered as epidemic prone areas.

Children and Pregnant women are usually the highest risk groups of Malaria, especially plasmodium falciparum that is the causative agent of more than 90% of all malaria cases in Somaliland.

9% of children experience an episode of malaria in Somaliland according the cluster survey. (Unicef,MoHL, 2000).

5. Acute respiratory tract infections (ARI):

In the developing countries 19% of child mortality is due to ARI.

Pneumonia (plus other acute respiratory tract infections) is considered to be next to Diarrhoeal diseases as far as morbidity and mortality are concerned. In one survey 2% of children interviewed reported that they have had an episode of ARI two weeks prior to the survey (Unicef, MoHL, 2000)

6. Malnutrition:

Although actual figures are not available at national level, UNICEF supported household survey show relatively good nutritional status among Somaliland children with severe Malnutrition of 3% and moderate malnutrition of 9%, mainly in the urban areas (UNICEF, MOHL,1999)

What health services are available for the children? Who provides these services?

Health care services are provided in two different sectors namely:

a. Public sector
b. Private sector

In the public sector, the functioning health facilities in the country are divided into three main categories such as:

a.1. Health posts: there are 135 health posts (HPs) evenly distributed in all the regions of the country. These health facilities are available at village level. Ideally there should be at least one Traditional Birth attendant (TBA) and one community health worker (CHW) in every health post(MOHL, 2001).

What health services are provided to the children?

Theoretically, CHWs are supposed to be trained for their job. They received short-term courses, but the component of children's health care is very insignificant, practically, therefore TBAs and CHWs can provided very little health support to the sick child. Few items are available in the Health post kit for children, such As ORS and rarely some anti-pain and anti-malarial drugs.

Major problems Identified:

- Many HPs are not functioning for one reason or another.
- Drug supplies are irregular and insufficient.
- Only UNICEF provides drugs for all the Health posts
- Motivation of TBAs and CHWs is usually low since they depend on community support only for their needs that is not mostly covered.
- Insufficient training of CHWs in general and towards children in particular.

a. 2. Health centres:

There are around 53 health centres throughout the six regions of the country(MOHL, 1999). Health centres (previously known as mother and child health care centres) are mostly located at the district capitals, some main villages and sections in the main cities.

They are staffed with:

- Qualified nurses (usually 1-3)
- Auxillary nurses (1-2)
- Cleaner
- Watchman
- And rarely one midwife.

The major units of health centre are:

- Under fives clinic
- Antenatal care unit
- Immunization unit
- Growth monitoring unit
- And adult OPD

What services did the health centres provide to children?

Health centres are the most important health facilities providing health services to the children. Both immunization and Growth monitoring units are exclusive for children (except the TT for pregnant women). Some basic essential drugs are available for children.

Vaccination, treatment of some endemic diseases and management of minor injuries are the most important health services children receive at health centres where they are available.

Major problem identified in this area:

- In adequate number of health centres in the country, so that there is no health centre services in many rural and Nomadic settlements.
- Irregular supplies in most of the health centres that are not supported by an INGO.
- Total dependency to Unicef as far as supplies are concerned.
- Lack of information channel between the health centres, the regions and Ministry of Health and Labour.
- Poor staff motivation
- Under utilization of people even in those well functioning Health centres.

a.3 Hospitals:

According to the official documents from the ministry of Health and Labour there are nine functioning Hospitals in the country, which are:

i. One National Referral Hospital in Hargeisa
ii. Five regional Hospitals
iii. One district Hospital
iv. One TB Hospital
v. One Mental Hospital

National and regional Hospital has various Departments such as:

- Surgical Department
- Medical Department
- Paediatric (not in all hospitals)
- Gyn/Obstetric Department
- Mental Department in most of the Hospital
- TB sections in most of the Hospitals
- Other specialities (in the national Hospital)

What are the staff categories of the hospitals?

- Doctors
- Qualified nurses
- Auxillary Nurses
- Lab. Technician assistants
- Mid-wives
- Other sub-ordinate staff.

What services do Hospitals provide to the children?

Hospitals are the highest level of health services provision in the country and therefore, they should have to provide all medical and surgical services that children need in any given time.

Children are treated in the Hospitals and some minor operations for children also took place in the hospital, but how what qualities of services are provided? How many beds are available for children in the hospitals? These questions and others cannot be answered easily and not well documented.

What problems exist in this area?

- There are no specialists (paediatricians) in the hospitals. All the doctors working in the paediatric department are practitioners without special skills for child illnesses and their management.
- There are also no paediatric nurses
- Most paediatric equipment are very scarce in the hospital, even emergency materials are hard to get.
- Staff motivation and thus patient care is very poor in almost all the hospitals
- No disease preventive measures are available at the hospitals except BCG Vaccination at the maternity wards.

The private sector consists several facilities that provides some sort of health services or another and these include:

b.1. Pharmacies: There are out-numbered pharmacies available in almost all sections of main cities, small town and even some villages; most of them are just drug sellers(Asha Hashi, 1997). They sell drugs of all types, and to every body. There is no quality control of the drugs they sell; there are no regulations and control of any sort. In most of them the persons running the pharmacy is unqualified and may even have no Health background.

b.2. Clinics: these are some facilities in which there are inpatients, they are found in the main cities, and mostly run by Doctors. The premises usually consists very few rooms. Almost all of them are in appropriate to admit any patient because of their low standard of sanitation measures, unqualified personnel and unavailability of basic medical supplies. Children are admitted in some of these so- called clinics.

b.3. Hospitals: There is only one private Hospital throughout the country and that is Mrs. Edna Aden maternity Hospital. In this hospital Neonates and mothers receive an international standard of health care services.

b.4. Consultation rooms: these are the facilities in which doctors work to receive patients, they usually deal with outpatients for drug prescriptions and some investigations.

b.5. Traditional operations sites: such facilities are operational in almost every corner of a city, town and village. Traditional surgical Practitioners run these sites; they usually deal with children and they carryout all the traditional surgical operations such as: Tonsillectomy, uvulectomy, teeth-extractions, nose bleeding and other harmful practices. There is no the least sanitation measures available in these sites and children usually suffer from such practices.

Apart from the psychological trauma that children experience from these practices it has a direct and indirect health problem such as: Severe haemorrhages, infections, nerve damages and many other complications. Unknown number of children dies due to such complications every day. Unfortunately there is no specific study carried out on this matter.

b.6. Traditional healers and herbalists:

These traditional healers use different methods of treatment. Some of them claim that they inherited the skill from their father and grandfathers. They mostly use various herbs and chemicals of unknown origin. The side effects of such drugs are unknown and there are no fixed dosages. Problems that result from such chemicals are very common among the population.

b.7. Tibi practitioners:

These claim that they treat their patients with some religious based practices in very different ways from reciting of Qur'an to plants.

b.8. Spiritual healers:

These are very common individuals who claim that the treat their patients through spiritual and supra-natural actions. Their actions are other superstitious or psychological. Some of them claim that "Satan" or "evil "affects their patients; and that they know how to fight against such unnatural elements.

What problems exist in the private sector?

The major problems that exists in this sector can be summarized in the following points:

- Poor quality of drugs.
- Lack of rules, regulations and control
- Untrained staff involved
- Unclean and unhygienic premises
- Inappropriate and insufficient medical equipment,
- Profit seeking, rather than patient's interests.

How children benefits from these private sector facilities?

It has been proved that 83% of the clients of the private sector are women and children ( Asha Hashi, 1997), but the qualities of services they receive are very questionable. The cost is also very high that most of the families cannot afford to pay for their sick children.

In fact some children may get some helpful health services in the private sector, but also there is many who suffer from malpractices, harmful interventions, and inappropriate and/or ineffective drugs.

No document, which tells something about the magnitude of the problem of traditional harmful practices, is available; and the whole area is so far obscure.

Who suffers most and how? How is the accessibility of good quality health care services?

From my personal point of view, all children from poor families, those in the rural and nomadic areas, those who are disabled in some way or another and those who are parentless or caretakers suffers the most. There is no clear policy to support such categories of children and youth. It seems that disabled, orphaned and children who have no other Adult caretakers are almost forgotten. There is no special programme focusing to alleviate the health problems of the least privileged children.

As we have seen there is no good quality health services in most of both private and public health facilities. Even those who are accessible and afford health costs may not get the quality of services they need, partly due to lack of trained staff and partly due to lack of appropriate supplies.

If we go back to the key questions for the children's situation analysis in Somaliland and try to investigate whether they were answered within the reviewed literature we can look at one by one and refer appropriate document for the answer of each question if it exists.

Let us begin with the cross cutting questions which the basis of situation analysis of the children.

The first question was: In what ways do girl's and boy's survival and development compromised?

In fact they were compromised in many ways such as:

- Wide spread communicable diseases that affects children as we have discussed before.
- Development of girls is specially compromised because of the painful female genital cuttings.
- There is a complete negligence of the vulnerable groups such as the parentless and disabled children.
- Early marriage also affects some children and young mothers.
- High maternal mortality (estimated to be 1600/100 000) rate directly and indirectly compromises the development of children.
- Lack of good quality health care services.
- Other possible factors

In the next question that says: In what ways girl's and boy's survival and development is supported?

Yes, we can say they are supported in several ways such as:

- Low percentage of malnutrition among children, which indicates that good physical development, is in place.
- Social system based on extended family with its values and individual care and insurance, may provide some assistance to those who have no first line caretakers.
- Government commitments to improve the children's situation as the CRC is ratified in the year 2001.
- Health policy that states to provide affordable and accessable health services to any individual.
- Significant health care support from the international agencies i.e. INGOs and UNOs.
- Other issues

In the next question of, which children are particularly vulnerable? In what way? What are the causes of their vulnerability?

It seems the most vulnerable children are:

- Those who live in remote nomadic and rural areas.
- Those who have no families in the urban settlements and
- Those from very poor families: these children have no access or afford the basic health care services, they have no safe drinking water and logically malnutrition can be prevalent among them. Out-breaks of Preventable/immunizable diseases are very common among these categories of children and youth.

Gaps identified in this area of vulnerable groups:

i. Insufficient studies, quantitative or qualitative, have been carried out in regard to these groups. The number of such children and their whereabouts are not known.

ii. The most common prevalent diseases are not also well documented, since most of the surveys are carried out at households level in urban settlements.

iii. There are no health strategies and policies set for the support of these groups, the ministry of health's strategic plan is based on cost recovery and cost sharing approach and there is no place for the most needy people; exemptions of charges for those who can not afford are not clear, but not even mentioned in most of the documents available.

iv. Other problems to be investigated.

Most of the remaining cross cutting questions cannot be answered within the texts of the literature reviewed.

The major areas that have not been touched were:

- Experiences of children with disabilities, without caretakers and without families.
- Difference between girls and boys were not identified.
- Opportunities and strengthens not well documented
- Multi-sectoral collaboration and cooperation, in regard to children's development, were not mentioned
- The extent of the international agencies assistance not known.
- Future plans to improve the situation of children in Somaliland are not in place.

What are the main health documents reviewed? and what other major health issues and information they contained?

Some of the main documents reviewed as mentioned before were: 1.Efforts to prevent HIV/AIDS in Somaliland, UNICEF/MOHL, 1999.

The purpose of this document was to provide measures of behaviour indicator for observing trend in high-risk behaviour in general and in selective social groups in particular.

The document is the end result of a large survey conducted through the country. The survey used both qualitative and quantitative methods, and data was collected form interviewees that consisted: Adult males (675) Adult females (1125) youth in secondary schools (975) long distances travelling merchants (225) drivers (150) and dockworkers (150) in addition to 325 interviewees of FLECs.

Main findings in this document:

- That women are more knowledgeable about STD/HIV than men.
- That youth did not responded well to the sex related questions
- That drivers are the most aware group on HIV/AIDS issue
- That the prevalence of HIV/AIDS was low among study population
- That prevalence of STIs is high among antenatal care attendants.
- And that no data for the situation of children in regard to STI/HIV/AIDS is available.

Comments on the document:

This document is valuable piece of work; it contains significant data, which was not available prior to this survey. It will remain a good reference for any body who is interested in this area.

What is missing and could not be carried out for one reason or another is the prevalence of the scourge among sex workers and adolescents.

Four years have already elapsed from the date in which the survey was carried out (1998), so it may not reflect the current situation.

2. Togdheer regional health plan:

This document was also reviewed as a sample of a plan for the regions; it is expected that all the regions has, more or less, similar plans developed at regional level with the support of central ministry of health and Labour and UNICEF, as the document stated.

The main targets of the plan were:

- To Improve Burao Hospital services
- Upgrade PHC services
- Introduce cost sharing system
- Advocate community participation in Health services
- Training of Health professionals

Comments about the documents:

It seems that the plan is so ambitious. Possible funding sources were not detailed and specified. Special activities for children were not mentioned apart for the routine health services. How far it was implemented at the moment is not clear, except that Burao regional hospital functions now far better than as it was.

3. Somalia standard treatment guidelines and rational use of drugs at PHC, WHO, 1998.

The purpose to the document is to be a training manual on rational use of drugs for Primary Health Care Workers in Somaliland and Somalia.

Comments about the document: the document is useful for training purpose, but it is not aimed for any action-oriented purpose. In the content of the document paediatric drugs are not discussed in detail, but some important treatment guidelines for children were stated in the document.

4. The National Health Policy, which is developed in 1999 by the Ministry of Health and Labour.

It is stated that the purpose of the document is: " to provide equitable and affordable preventive and curative health care services and thus ultimately better health status i.e. reduce morbidity and mortality that will result in increased life expectancy"

Comments: The document does not address the special needs of the children in general and the vulnerable groups in particular. It is mostly a broad statement without specifications. The document seems that it was not edited seriously because many errors of various nature identified.

5. Baseline KABP survey on Reproductive Health and Family Planning in Somaliland and Puntland. WHO Somalia, October 1999.

The Main objectives of the this KABP Survey was: to provide baseline information on reproductive health including family planning, abortion and sexually transmitted diseases as well as other health measures such as: IMR, CMR, NMR and knowledge about the most prevalent disease in the community Viz. Tuberculosis.

The survey was carried in 639 households in two regions namely: Galbeed and Awdal.

Comments:

Although the sampling was based on the population estimation of UNDOS (1,100 000), which far less than the official population estimation of the ministry of planning and other organizations (around 3000 000), the document contains very important data and information which otherwise would have not been possible.

The survey would have been more representative if at least one of the eastern regions would have been included and if the sample size would have been little more.

The main findings, and possible answers for key questions, stated in the document are:

- Fertility rate of around 7.9
- NMR, IMR and CMR, which are estimated to be 28,113 and 328 respectively.
- FGM Prevalence of 99%
- 18% of married underage (<18) girls

6. Guidelines for establishing private health care facilities and practices in Somaliland, MOHL.

The Purpose of this document is stated as: To formulate rules and regulation for the private sector.

The document is not well prepared; it has no time schedule, no specifications and no clear activities to be carried to fulfil this very crucial issue. The document needs to be reviewed, edited and up-dated.

Does it answer any key question of the situation analysis of children in Somaliland? NO, Nothing special for children is mentioned.

7.Case study on FGM practices in Togdher region, Somaliland, SCF- UK field community development staff, April 2002.

The main objectives of this study stated in the document were:

- To understand more about FG practices in Somaliland.
- To know what activities are undertaken against FGM and who did it?
- To recommend appropriate and feasible approaches to address the problems of FGM in Togdher region.

Main findings were:

- FGM is widely used and more in the community and that the most predominant form of circumcision is the pharonic type.
- That both acute and chronic health problems are very common with some serious consequences.
- That most of the people wrongly believe that FGM has religious basis and that it is a crime if it is not carried out.

Comments:

Although it is stated that both qualitative and quantitative research method are applied in the study, it seems that the sample size (140) is very small and can not be representative not nationally but even at regional level.

8. Five years strategy health Plan 1999-2003, MoHL 1999.

As the title indicates the purpose of this document was to develop a five years health strategic plan for the country.

Comments:

Only one year remained from the time schedule of this strategic plan. What activities mentioned in the plan that has been carried out and which were not, is beyond the scope of this report, but it seems that most of the activities mentioned in the document were not fulfilled for one reason or another. Who should implement what? How it should be implemented and when? What resources where available to materialize the plan? are all questions that are not responded and not even proposed in the document itself.

It seems that the document was developed focusing only on Health sector reform.

There are no significant specific issues concerning support of children mentioned in the whole document.

9. Maternal and Neonatal Health, community level component, UNICEF, Somalia, October 1999.

The purpose of this document is to develop a strategy for reduction of Maternal and Neonatal mortality and morbidity in Somaliland and Somalia.

Several studies showed that Maternal Mortality Rate (MMR) is exceptionally as high as 1600/100 000.

Certain underlying causes of this high MMR are:

- Post FGM related complications
- In adequate maternal health services
- Unskilled birth attendants
- Low level of education
- Malnutrition with anaemia during pregnancy
- Poor and delayed referral system.

To reduce this high Maternal Mortality rate (which directly and indirectly affects children) several action points were suggested such as:

- Training of Birth attendants
- Improve referral system and early recognition of complicated pregnancy.
- Increase community awareness about maternal complications
- Development of clean delivery kits to reduce infections
- Eradicate the Female Genital Mutilation
- Conduct applied research

To implement such action points would have been crucial and a great support for the mothers in need, but how, who, where and when? All needs to be discussed and planned by all health stakeholders and partners in the country.

10. Maternal Health services, UNICEF Somalia 1999.

The purpose of this document was to develop guidelines on Maternal health services provision for programme planners and managers in Somalia and Somaliland.

It is stated that 10 (ten) women between the ages of 15-45i.e every day in Somalia (including Somaliland) as a result of pregnancy related complications, so in every year up to 110 000 pregnancies result in severe complications, Illnesses or permanent disability of the mother and Child. Over of all under-five deaths occur in the first week of life due to complications during pregnancy and/or delivery.

So to reduce neonatal deaths it is an utmost importance to reduce maternal complications in its various forms.

11. Integrated management of childhood illnesses (IMCI) in Somaliland, Gladys E. Martin, July 2001.

The purpose of this document was to provide technical support to Somaliland Ministry of Health and labour, as well as to UNICEF Hargeisa staff, in the field of the integrated management of childhood illnesses.

It is realized that a sick child can present two or more common killer diseases concomitantly, to tackle with this problem IMCI has been successfully implemented in several developing countries, so this document is developed how to apply such approach of dealing with childhood illnesses.

In the document it is stated that 11-12 million children die every year in the developing countries. Up to 70% of these death are caused by the five major killer diseases namely: ARI, Diarrhoea, measles, Malaria and tuberculosis.

In Somaliland the IMR is estimated to be around 175, <5 mortality rate is around 250/1000.

Comments: the propose programme in the document (IMCI) is still on paper and never implemented. There is no clear plan of action to put the proposal into action. Childhood illnesses do wait any body, and even if further studied the situation could be worse than stated here.

12. End decade multiple indicators Cluster Survey, full technical report for Somalia, UNICEF 2001.

The purpose of this surface was:

- To provide up-to-date information of assessing the situation of children and women in Somalia and Somaliland at the end of the decade.
- To furnish data needed for monitoring progress forward goals established at the world summit for children.
- To get basic data for future actions

The survey was well organized and prepared, in Somaliland the survey was carried out in 100 cluster each consisting 44 households. The clusters were distributed in Urban, rural and Nomadic ones.

According to the findings of that survey:

- Only 20% of children aged less than 4 months were exclusively beast-fed.
- Low birth weight children were relatively low in Somaliland
- 9.3% of the children had immunisation cards.
- 17% of children in Somaliland have had Diarrhoea in two weeks prior the survey.
- 2% have had ARI
- Around 9% of children had an episode of malaria.

Comments:

Very significant, referable data is available in the document, the methodology was very satisfactory and focusing the objectives of the study; any how certain issues concerning children were not addressed and these included: the situation of children who do not live in households, the quality of health care services provided in different health sectors, the major psycho-social problems of children, the morbidity rate of major killer diseases etc.

Although the survey was not limited to Somaliland but all of the previous Somali regions, end decay indicators cluster survey is one of the most informative surveys ever conducted in Somaliland, particularly in the field of health. It contained a significant portion targeted on children and mothers.

13. Knowledge, Attitude and practice in North West Somalia, UNICEF, 1998.

It is stated that the purpose of this survey was to understand the current knowledge, attitudes, and practices in the areas of Health, water, sanitation and hygiene.

The survey was conducted in 25 clusters of 24 households each (600 households in total) distributed in the six regions of the country.

Some of the main findings that worth to be mentioned are:

- Under utilization of the few public health facilities available.
- Leading diseases in all the facilities were: Measles, ARI, Diarrhoeal/vomiting, malaria and malnutrition.
- No difference of disease prevalence among the urban, rural and Nomadic settlements.
- High utilization of the private sector and great dissatisfaction of the services received.
- Only some mobile teams have reached in most of the rural and nomadic areas.

Comments:

The sample size seems small it would have been more representative if larger sample would have been selected. The methodology was not bad and there are some interesting findings highlighted in the analysis of the survey.

There were no any specific findings for children, and the study did give any special consideration to the issues of the children and other vulnerable groups.

14. World report on violence and health, World health organisation, Geneva, 2000.

This document was rather a reference one, but we reviewed because it contained some burning issue concerning children worldwide in general and were violence is wide spread in particular.

One of the major purposes of the report was to clarify or prove that where violence persists health is seriously compromised.

Apart from non-fatal abuses and neglect on children, 57 000 children were killed in the year 2000 alone. 0-4 years age group were those mostly affected.

It has been recommended:

- To promote primary prevention responses.
- To strengthen responses for victims of violence
- Increase collaboration and exchange of information on violence prevention.
- To promote and monitor adherence to international treaties, laws and other mechanisms to protect human rights.

15. Strategic plan framework, a guide to improving health care service delivery in Somaliland, November 1997.

The document is a report of a workshop organized by the ministry of Health and Labour.

The purpose was to conduct a participatory workshop to analyse the Health situation and formulate a National Strategic Health plan Framework for Health to guide the health sector development process in Somaliland.

Main findings of the workshop were:

- Lack of policies, guidelines, regulations and standardisations for health service delivery at central level.
- Poor patient care management at Hospitals
- Inadequate resources
- Lack of quality control of medical supplies
- Unqualified and unmotivated health staff
- Lack of confidence of the community in the public health services
- Lack of new graduates and health cadres.

Comment: The document was just a report, it has no much value for children situation analysis at this moment, but it is an indication that no point concerning children was mentioned in the outcome of the workshop like many others.

16. Children and women in Somalia, a situation Analysis, UNCEF-Somalia, May 1998.

The purpose of the document was to provide as comprehensive a picture of the present situation of children and women in Somalia and Somaliland as possible, and to describe not only the problems but also the existing capacities and opportunities arising from the situation.

Main findings of the situation analysis:

- Maternal mortality rate and child mortality rates are the highest in the world i.e. MMR= 1600/100 000 and CMR= 211/1000
- Poor quality and inadequate health care services, which doesn't even exist in many rural and nomadic areas
- Poverty and Illiteracy plays a great role in deteriorating the health situation
- High prevalence of certain communicable diseases which could be both preventable and curable such as: Tuberculosis, Measles, ARI, Cholera and other diarrhoeal diseases, malnutrition, Anaemia, Hepatitis, Tetanus and pregnancy related complications.
- Lack of family and reproductive Health
- Untrained and under-qualified health professionals
- >90% of health resources are donor dependent.
- Unregulated and controlled private health sector.

Comments:

The document contains all the above and more information concerning Health issues, but for one thing it is for all Somalia and not specific for Somaliland, and in another thing it has no clear indicators and subsequent action points.

17. The Role of the private sector in the delivery of health services in Somaliland, Situation Analysis and strategy formulation, Asha Hashi Abdulla, 1997

The purpose of this relatively old document was: To develop strategies pertaining to the private sector, to formulate comprehensive policies and guidelines for this non-governmental sector, and to get some in depth study on the situation of the private health services.

Main findings:

- The private sector is operating without regulation, quality control and standard protocols.
- Because of lack of confidence in the public sector, most of the people look for support of their health problems at the private sector.
- Most of the staff in the private sector also works in the public sector and there could be a conflict of interest.
- More than 80% of the consumers of the private sector are women and children.
- Many untrained workers are involved in the private sector.
- The private sector is relatively expensive, so many cannot afford.

Comments:

The study was confined in Hargeisa and therefore may not be representative, but the methodology of the study was outstanding and since Hargeisa is the capital city with a population almost the same to the population of all other major cities in the country together, the results of the study can be projected to the other cities as well.

18. Report on STD/HIV Prevalence Study in Somaliland, Gillian Duffy, November 1999

The purpose of this study was to determine the magnitude of the prevalence of sexually transmitted disease and HIV/AIDS in Somaliland, in order to develop their effective and integrated strategies for prevention and control.

The study was carried out in four of the six regions of the country namely: Galbeed, Awdal, Sahil and Sool.

Three target groups were selected:

1. Women of childbearing age attending antenatal care of the health centres.
2. Patients in TB Hospital of 15-49 age group
3. Group of Adult men 15-55 years age.

Main findings:

The prevalence of STIs are high among the study cases i.e. around 30%, but the prevalence of HIV/AIDS is very low i.e. <1%. The prevalence of HIV/AIDS of the TB cases where higher and reached 8.8% among study cases in one region.

Comments:

The situation of STIs/HIV/AIDS among children was not touched neither in this study nor other studies reviewed.

The direct and indirect effects of STIs in children are well know, but it seems that it has been neglected in this country.

The high prevalence of STIs among mothers attending ANC can be a clue that STIs may also affect significant number of children, but how and how much are not identified.

19. Several miscellaneous other document which were mentioned before were also reviewed.

Conclusion:

Having reviewed all the aforementioned health and health related documents, Given the long personal experiences, having in mind the most appropriate questions asked in the terms of references of the children's situation analysis, Given the reality that there is NO continuous analysis of children's situation and therefore nobody can claim that he /she knows the exact situation of children in Somaliland. Anyhow we would like to summarize the main findings that could be some indicators of the situation of children in Somaliland.

To simplify the conclusion we put it in the following table form, beginning with primary health care components:

Question

Findings, what is known?

Gaps, what isn't known

1.How is the level of immunization coverage? Who provides vaccines? How it goes on?

-It is stated in several documents that it is less than 30% of < 5s.
- All vaccines(Except for Meningococcal meningitis) are provided by Unicef and they are available at health centres
- Recent data of the current immunization coverage is not available at national level, so what is the current situation?
- main reason underlying low immunization coverage not detailed.
- state of immunization of the vulnerable groups not studied.
- How many children due to immunizable diseases not known?

2. Is there adequate supply of water and sanitation? Which areas are more affected if there is shortage?

It is documented that there is inadequate water sources in all areas. The rainfall is usually low, and water systems at the main cities are not well established.

More details are needed in this issue, particularly the situation in the poorest settlements? How is the sanitation in these areas? What is the prevalence of water related diseases not known?

3. How is the availability of food and proper nutrition? What are the main sources? Who is in Malnutrition is reported in few districts, use of animal products are very common, children in no large scale survey document could not be available for the team to review in this regard danger to develop Malnutrition?

- Malnutrition is common in Nomads only during droughts, or epidemic diseases, it seems more common in adolescents, if so why? Is there difference between girl's and boy's adolescent age group? 4. How many health facilities especially for mother and child health centres are available for mothers and children?

Around 53 Mother and child health care centres are available in the country, but the number of mother and children who get appropriate health services is very low

- There is under-utilization, Why?
- Poor staff motivation, why?
- Irregular supplies, why?
- why not possible to increase the Health centres?

5. Is there sufficient Health education towards prevention of communicable disease?

Clearly, according to some KABP most of the people need more Health education

- Satisfactory data is not available (not reviewed).
- what knowledge do children have about disease prevention?

Is there any other preventive measures in place particularly in the less privileged areas?

6. Do endemic diseases well controlled and tackled?

The answer is negative, prevalence of most of the endemic diseases is high Why? Do children know endemic diseases? Are endemic disease same in all districts? Who should the direct responsibility of dealing with endemic diseases?

7. How is the availability of essential drugs? Who provides? Where they are available? Who developed and why?

Essential drugs are not available in most of the facilities. International agencies provide most of them in particular areas and programs, but not very regular.

- How much funds the government allocated for Essential drugs(E.Ds)?
-What sort of drugs are needed the most, specially for children?
- what is the availability of essential drugs in the rural areas?
8. How is the control and prevention of epidemic diseases? What are the main epidemic prone
-With low immunization coverage and inadequate health services, control and prevention of
-Is there any plans to tackle with disease epidemic prone disease?
-How many laboratories diseases? When they occur? Where they occur?
- Cholera, malaria, measles, whooping cough and Dysentery are the most prevalent epidemics that occurs every time and then. They occur anywhere any time. have capability of Identifying the causative agents of these diseases?
- The impact of these diseases on children are not well documented.
- availability of appropriate drugs of these diseases.
- which categories of the populations are more affected during the epidemics.

9. How is the mental health care? Is there any mental health care for children? Who provides and How?

Except some mental wards in three regional Hospitals, there is no other public or private facilities that cares mental health, and nothing for children

What sorts of mental disorders are seen in children in Somaliland? How prevalent they are and who are mostly affected?

- do paediatric drugs available for mentally disturbed children.

10. What are the key problems affecting Girl's and boy's health & Development? -FGM
- Malnutrition
- Inappropriate health services
- the exact magnitude of these developmental problems are not well known.

11. What are the causes of children's ill health? What are the main diseases? How they are dealt and by whom? Do we have all data in this regard?

- Common childhood illnesses
- Anaemia
- Diarrhoea/vomiting
- Pneumonia
-Tuberculosis
-Traditional harmful practices
- Hepatitis
-The morbidity and mortality of most of these diseases are not known; --other important disease not even documented.
-The underlying causes were not highlighted in some of these diseases?
- what plan are available to deal with these health problems.
12. What is the extent of children's access to good quality, affordable health care?

Where are the sites? Who benefit most?

Given limited health facilities, unqualified staff and lack of resources, good quality and affordable health care is not accessible to the majority of children. Facilities are located only in urban and Semi-urban areas. The majority of

- The quality of health services available both in the public and private sectors are found to be poor and unsatisfactory, why?
-What about the accessibility of health facilities for the most poor settlements in the the population live in Nomadic areas and are not accessible to health care services main cities? Where do they seek help for their ailments?

13. What is the situation of FGM? Are there any behaviour changes?

Why it is continued despite all related problems seen by everybody? What is needed to eradicate the scourge?

FGM is widely practiced and more than 97% of girls are circumcised, and it seems that there is no behaviour change in this regard, there is a strong believe that the practice has religious basis. Its eradications will take a long time so, long-term plan is needed to establish.

More update data and KABP is required.

The fight against this harmful practice needs to be empowered, with the participation of all sectors of the community specially religious leaders and Mothers.

14. In what ways are boy's and girl's survival and development being compromised?

- wide spread communicable diseases
- FGM for girls.
- Malnutrition in some areas
- Poor health care services.
- Lack of health education
- Recent data on Morbidity and mortality of major diseases
- situation of vulnerable groups 15. In what ways are boy's and girl's survival and development being supported?

- Provision of vaccines in the urban areas
- International and national agencies endeavour to the situation of children.
- development of some policies and plans to upgrade children's health status.
- what kind of support given to whom and by whom is not all well known? 16. Which children are particularly vulnerable and /or are subject to discrimination? In what way ? what are the causes of their vulnerability?

- there are many children with very poor families in urban settlement.
-Children in Nomadic areas don't have any significant health services.
- there are children without caretakers.
- there are significant number of disabled children in the country with out proper support
-What are the major health problems of the vulnerable groups are not studied?.
-What is the level of immunization coverage among vulnerable groups?.
-where such groups seed for health services?.
- who pays for their health expenses?.

How are girls affected? In what way boys and girls experiences differ?

FGM is a problem that affects girls only.

No other differences were identified

What is the experience of children with disability? And those from minorities?

- what is experience do disabled children in regard to health issue is not known?

What girls & boys families and communities say will help them improve children's situation? Not much

The attitude and ideas of communities and families towards the improvement of childrens situation is not documented as far as health is concerned

What suggestions are made on the organisations working with and on behalf of children?

Several organizations such as: Unicef, SCFs, WHO etc do have some programmes and strategic plans to support children.

Implementation plans are not in place.

N.B: It has been mentioned that most of the documents reviewed were not very recent, that the may not reflect the current situation of children in Somaliland.

REFRENCES:

- Efforts to prevent HIV/AIDS in Somaliland, Unicef/MoH & L, 1999
- Togdheer regional Health Plan, MOH & L /Unicef, 1999
- Somalia Standard treatment guidelines and rational use of drugs, WHO, 1998
- The national Health Policy, MOH & L
- Baseline KABP Survey on Reproductive Health and family planning in Somaliland and Puntland, WHO, 1999
- Guidelines for re-establishing private health care facilities and practise in Somaliland. MOHL
- Case study on FGM practice in Togdher Region, Somaliland, SCF-UK April 2002.
- Five year strategy Health plan 1999-2003
- Medical information for international agencies in Somaliland: INGO Focal point December 2001.
- Maternal and Neonatal Health, Community level component. UNICEF, October 1999
- Maternal Health services, Unicef Somalia, 1999
- Integrated management of childhood Illnesses in Somaliland, Gladwyne. Martin, July 2001
- End decade multi-indicator cluster survey, full technical report for Somalia, UNICEF, 2001
- Knowledge, Attitude and practice in North West Somalia, UNICEF, 1998.
- World report on violence and Health, WHO, 2000
- Strategic plan framework, a Guide to improving health care service in Somaliland, Nov.1997.
- Children and women in Somalia, A situation Analysis, UNICEF-Somalia, May 1998
- The role of the private sector in the delivery of health services in Somaliland, Asha Hashi, 1997
- Report on STD/HIV Prevalence Study in Somaliland, Gillian Duffy, November 1999
- Immunization policy, Global programme for vaccines and immunization, EPI, WHO
- Supervision Tools for health service Delivery system in public Health facilities, MoH & L, 2000
- The National HIV/AIDS Awareness Seminar, September 1999
- Somalia Nutrition Update, FSAU, 2000
- Questionnaire for youth
- Questionnaire for the improvement of Reproductive status in Togdheer Region.
- Hargeisa water supply, Groundwork for future collaborative Action, UNCHS, 1996