Somaliland Scoping Visit
- Background and History:
Population 3.5 million; 6 Regions; 21 districts; Blindness estimated at 1.2%+;
Pathology: Cataract, Trachoma, Glaucoma, URE and trauma.
Somaliland has shown extraordinary determination to succeed. The former British protectorate merged with the UN trust territory of former Italian Somaliland to become the Republic of Somalia in 1960. After 9 years of democratic government the Republic was taken over by Siad Barre’s forces in a coup. Long-standing differences between the north and south of the country resulted in civil war. Social services and infrastructure were almost totally destroyed and many trained medical workers left the country or were killed, with mass displacement of the population. After a 3 year war the Somaliland National Movement emerged victorious and declared independence from Somalia in 1991.
Those governing Somaliland have shown respect for democratic principles, begun to develop natural assets, which will strengthen the economy and have rebuilt much of the capital city, Hargeisa.
After 24 years of parliamentary democracy and at least 4 separate peaceful changes of the Presidency and Government, Ethiopia is still the only country to recognize Somaliland with diplomatic relations. The country is at peace and the security situation is good – in stark contrast to the problems further south. The lack of recognition has resulted in Somaliland becoming an orphan state with most development resulting from local efforts and funding from the diaspora, not from international aid donors. Recently Australian Doctors for Africa have been active in the health sector and they have noted the great need for eye health development and hoped that the Fred Hollows Foundation might join with them and others who have noticed the Somaliland determination to implement responsible and sustainable eye health care.
The Foundation’s interest in Somaliland was first raised in 2009, following direct approaches to the Medical Director by members of the Somaliland diaspora,living in Melbourne. These were followed by invitations to visit from the then Minister of Health, Dr Hussein Mahamed, the Director General Medical Services and the Director of the Regional Hospital in Berbera. They requested assistance from The Foundation to train 4 nurses (as Mid Level Ophthalmic Providers – MLOP) in any of several training institutions Ethiopia. At that time the cost for such training was only $15,000 for all 4 nurses.
A Concept Brief to scope the situation on the ground was prepared and submitted in 2010 but was rejected as being premature and a distraction from establishing a presence in Ethiopia.
Following the recent NNN and associated meetings in Abu Dhabi and at the invitation of the current Somaliland Minister of Health, Dr Suleiman Ahmed Isse and further suggestions and invitations from Dr Graham Forward of Australian Doctors For Africa (ADFA, based in Perth, WA), Dr Richard Le Mesurier and Dr Wondu Alemayehu visited Hargeisa and Berbera to gain first-hand experience of eye health needs for this small, independent but unrecognized country, bordering the Oromia and Somali Regions of Ethiopia.
- Visit Agenda:
- To assess the eye care situation in Somaliland and the Health System
- To prioritise the eye health needs and gaps in Hargeisa and Berbera
- To assess the significance of trachoma in Somaliland, particularly in regard to potential cross border issues with the Somali Region in Ethiopia. No mapping has been done so the GTMP need will be reviewed.
- To meet with the Ministry of Health and other eye health stake holders.
- To meet with and assess potential program partners in Somaliland, particularly the Taakulo Somali Community.
- Housekeeping and Organisational Notes:
Flights: Hargeisa can be reached in an hour from Addis Ababa on Ethiopian Airlines costing AUD$720 return. From Abu Dhabi it was complex and time consuming via Muscat and Addis Ababa but we subsequently discovered Hargeisa has direct flights to and from Dubai on fly Dubai airlines – a journey of 3.5hrs costing USD$600 return on Saturdays, Sundays, Tuesdays and Wednesdays.
Visas: need to be obtained electronically via email. The visa costs USD$5 but in addition there is a USD$60 Visitor Tax, to be paid on arrival in cash and receipts are issued.
Money: US$ is used by everyone although the Somaliland Shilling is also used by locals. NO CREDIT CARD ACCEPTANCE or ATMs but funds from international sources are transferred through official money transfer processing. Corruption does not figure and accountability relates to high degrees of motivation.
Hotel Accommodation: There are several adequate hotels in Hargeisa. We stayed at the Mansoor Hotel @$50/night with clean rooms, fly wire and fans. No A/C. Food good but strictly no alcohol at all as it is a Muslim country.
Electricity: UK square 3-pin system; 225V, seemed stable.
WiFi: excellent at hotel. Good free and mostly fast Internet service.
Mobile Telephones: widely used by everyone. SIM cards available at airport and Telcom offices. Skype and Whats App used a lot.
Water: bottled best – probably essential.
Internal Travel: Government insists an armed guard accompanies visitors traveling outside Hargeisa. The guard costs $20/day and sleeps in the back most of the time.
Climate (in September) warm (c.28C) and quite fresh in Hargeisa (alt 1334m); Very warm (40C max) in Berbera at sea level and much more humid. Cooler in December to March, hottest in July/August.
- Main Contact Organisation: Taakulo Somali Community (TASCO).
TASCO, a local NGO, was founded and is run by Mr Omer Jama Farah who is a highly organized man with excellent contacts throughout Somaliland. We were introduced to him and his organization by Australian Doctors For Africa, who depend upon TASCO as their main in-country partner.
TASCO works together with several international organizations in the field of development, focusing on health, WASH and education in particular. Dr Graham Forward, Orthopedic Surgeon from Perth, WA, introduced us to TASCO and it made a huge difference to all we were able to do.
Despite many promises and invitations from government, it was difficult getting useful emailed feedback or ensuring appointments were made through official channels. TASCO was able to arrange visas within a few hours, emailing them to us in advance. They also met us at the airport, arranged comfortable affordable hotel accommodation, arranged appointments for us to meet Ministry of Health senior officers, Hospital Directors, and the two most active ophthalmologists in the country.
TASCO provided us with transport to Berbera and arranged the guard to accompany us there and back. These achievements were all the more impressive as the whole country was about to go on holiday for the Eid al-Adha and most civil servants and government officials were closing up and getting ready to visit families and relatives.
- Somaliland Itinerary and program:
Sunday 20 September:
Arrived Hargeisa from Addis Ababa on Ethiopian Airways in the morning. Met by Mr Omer Jama Farar of TASCO, escorted through Immigration and Customs and taken to Mansoor Hotel on the opposite side of the city where the President was attending a reception. It was all quite casual, despite high security. Checked in and rested. Had discussions about the plans of the visit and some background exchange of information.
Monday 21 September:
Meeting at MOH with Director of Public Health Dr Abib Aden and other officials. We were given some background health information and the current priorities for health education and promotion, with an emphasis on hygiene and WASH.
Dr Aden thought that active trachoma was not such a problem any more following strong hygiene messaging and promotion by mobile phone broadcasting – but there have been no surveys or mapping and we got the impression that most opinion was based on experience from Hargeisa. Dr Aden was very positive about the possibilities for GTMP mapping surveys and assured us that local staff could be made available if external trainers could be made available, preferably from Ethiopia: Oromia or Somali Regions (FHF or LFTW) are closest and language less of a barrier. Although there has been some informal eye care training they have no formally trained MLOP but there are some young ophthalmologists in training abroad.
Dr Aden was very supportive for the idea of developing a cadre of Mid Level Ophthalmic Providers (MLOP) if we can arrange for them to be trained in Ethiopia. Already good links exist with Jimma and Alert hospitals for training specialized cadres and we had the impression that the government would be happy to be involved in selecting the best possible candidates and supporting them.
Meeting at Hargeisa Group Hospital with Dr Ahmed Omar Askar, Hospital Director and also with the local ophthalmologist Dr Ali Omar and a couple of surgeons who have worked with Australian Doctors for Africa. We then visited a very impressive Renal Dialysis unit that ADFA and TASCO had helped set up.
The eye OPD and OT were very clean but had an air of being mostly unused:
Basic equipment was present (like slit lamp and microscope) but few consumables and no IOLs. All very clean but lacking much infrastructure, wiring was loose, cracks were common in the walls and the ophthalmologist, Dr Ali Omar seemed resigned to the general lack of equipment. The operating microscope was a good basic Zeiss with teaching arm and could be used for training. There was also a huge Leica ceiling-mounted microscope donated by the Italians – but with no manual and no knowledge on how to mount or use it. Thus it is a wasted donation. We advised that the donors be contacted for assistance.
We heard that ICCE is still done by some surgeons and most are doing some private practice as the Hargeisa Group Hospital is so lacking in equipment, especially consumables.
In the afternoon we visited a Turkish-funded Primary School where we examined a few cases of allergic conjunctivitis amongst the children but no TF – not surprising in this urban middle class school. All children had clean faces and good clothing.
Tuesday 22 September:
Visit to the private clinic of the most active ophthalmologist in Somaliland, Dr Ahmed Nur Ismail. He is well known and very experienced, having worked around the country, including Mogadishu, over the past 20 years. He is also acknowledged to be the best ophthalmologist in the country. He does all of his surgery at the Manhal Hospital. Manhal is a private hospital and Foundation that does both private and charitable work, focusing on quality outcomes.
Unfortunately we did not get the opportunity to visit Manhal while we were there but this should be a priority for the next visit. Dr Ahmed told us he mostly did cataract surgeries but also did quite a few TT (Trichiasis) surgeries. He has done outreach to a couple of places in the country, including Berbera and Burau but the problem is time and the fact that there is no pre-outreach screening of patients. Also no local ongoing basic eye care is possible without eye-trained nursing staff. Dr Ahmed would strongly support such a development.
Meeting with WHO at the highly fortified WHO office. The fortifications looked rather excessive since few other buildings in the city were so protected but we were told this was done according to UN standards. We had a good meeting although the WHO staff we met were not particularly informed about eye care. The office comes under EMRO based in Cairo and Somaliland is thought to be much safer and preferable to Mogadishu. An old Ethiopian friend and colleague of Dr Wondu, Dr Assegid Kebede Tesema, works with WHO in Hargeisa running the EPI programme. He is potentially a useful unofficial source of information.
Wednesday 23 September:
Drive to Berbera; Roadside clinic; Meeting at Berbera Regional Hospital for discussions with Hospital Director; Visit to refurbished OT and Eye clinic; Return to Hargeisa.
Mr Omer drove us to Berbera (4 hours) using the TASCO vehicle and had also arranged the obligatory (but unnecessary) armed guard to accompany us in the vehicle. The road was in good condition mostly and only busy close to Hargeisa. It was interesting to note how arid the countryside was with small very scattered villages. Not much sign of arable agriculture but goats and black-headed sheep were common, as were camels.
About half way we stopped at a village or small roadside town with a Health referral clinic.
The nurse introduced us at the small market and soon we were surrounded by people of all ages wanting their eyes examined. Most of the children complaining of ‘trachome” actually had allergic conjunctivitis and we saw no TF.
As we were on the main road between Hargeisa and Berbera most people would have reasonable access to eye care if they could afford the transport. They also were well equipped with mobile phones and obviously targeted for health promotion messaging. A very high proportion of the elderly, however, had cataracts and we saw some examples of shrunken eyes from unsuccessful cataract surgery in several older people.
We continued to Berbera, to visit the Regional Hospital. There we met the very forward thinking Hospital Director, Dr Asha Guled – a dynamic woman with great initiative and determination. She has organized training in Orthopedics for the OT assistant, Mental Health training for another staffer and had refurbished old buildings into a new Dental Centre and an Eye Centre. She arranged for an optometrist to hold regular clinics in the eye centre and has offered the facility to be used for outreach from Hargeisa. When we explained that we thought a major gap in the system was MLOP and explained their function and roles she was very enthusiastic, completely understanding and offering to identify suitable nurses for training. We were then shown around the hospital and new clinic,
before the drive back to Hargeisa.
Thursday 24 September:
Eid al-Adha, the start of the Somaliland annual holiday.
We had wrap-up discussions with Mr Omer before being delivered by him the to airport, departing to Addis Ababa and Melbourne.
- Somaliland has obvious need. To start with the priorities should be
- Trachoma GTMP mapping, if possible with DFID funding.
- HRD to start with MLOP training in Ethiopia for 4 selected nurses from Berbera Regional Hospital.
- The main reasons for considering intervention at this time are related to
- social justice for 3.5 million people ignored by UN and the African Union
- rewarding a community that has fought for and successfully defended its right to democracy and self-determination
- MOH, government and all local political parties are supportive
- TACSO ideal as an effective, well connected facilitating agency
- great potential (and need) for comprehensive eye health development
- achieving elimination of blinding trachoma in Somaliland
- The Ministry of Health is receptive and cooperative and supports the development of a National Eye Health Plan, HREH and trachoma mapping. Welcomes international development assistance.
- Ethiopia is close and relations with Somaliland are good, facilitating the training of MLOP/ophthalmic nurses at an affordable cost. There is also practical training expertise over the border in Oromia, Tigray and Southern Nations for training of Graders and Recorders for GTMP mapping.
- That would benefit all parties in also addressing the potential Trachoma cross-border issues.
- We have been assured by TASCO that MOH can and will appoint a National Trachoma Coordinator without delay and is very happy to develop a National Eye Health Plan. Following GTMP surveys it understands the necessity to have a Trachoma Action Plan.
- Logistics and fund management might be tricky as banking is affected by lack of international recognition. There are ways of getting round that, which have enabled the already significant progress that has been made through local and diaspora-based funding.
- These orphan countries are being discussed but as yet there are no clear guidelines – often an opportunistic approach is needed.
- Coordination and implementation could be done through FHF, Light for the World or Orbis offices in Addis Ababa. Dr Graham Forward of ADFA has confirmed to us that TASCO is well connected and its track record in overall management, including finance and admin, is fantastic based on years of experience. We have also observed the same first hand.
- Importation of goods is far simpler in Somaliland with access by sea, air and also by road. The Customs authorities are also more sympathetic than those in Ethiopia.
- Finally, because of the historical links with Great Britain, such a project might be directly attractive to Sightsavers.
Richard Le Mesurier & Wondu Alemayehu 18.10. 2015
Somaliland scoping visit trip by Micheal and Wondu
Report on scoping visit to Somaliland by:
Wondu Alemayehu (MD), TA, TFHF and Dr. Michael Dejene (Epidemiologist and Member of the DFID/Trust Technical support team representing, Sightsavers).
Date: Aug 17-19, 2016
- Baseline assessment of trachoma and develop concrete plans to conduct trachoma survey in Somaliland
- Determine the potentials for building human resource need for eye health in Somaliland with a focus on Mid-Level Eye Care Workers
Leadership staff of Potential Partner organizations in Somaliland, Hargeisa:
H.E. Mr. Hassan Dhimbil-Deputy Minister of Health, Ministry of Health, Somaliland, Hargeisa
Mr. Jamal Mohammed Geddi – National Trachoma Focal Person MOH, Somaliland, Hargeisa
Dr. Yasin Arab Abdi – General Director, Manhal Hospital
Mr. Omer Jama Farah Director and Founder Taakulo Somali Community (TASCO)-Host Organization
Mr. Mahmud M Duale, Program Coordinator Taakulo Somali Community (TASCO)-Host Organization
- The total population is 3.5 million.
- There are six regions and 21 districts in Somaliland (Northwest Zone Somalia)
- Shares borders with Ethiopia and South Sudan both having trachoma hyper-endemic areas
- 5 ophthalmologists and only one ON in Somaliland.
- Very limited number of highly needed mid-level eye care professionals working in Somaliland.
- The team visited three rural communities namely Gelooley, Tog-wajaale and Geedabera for observation and to carry out a quick assessment of active trachoma among children age 1-9 years. The visited villages are located between 45 and 90 kilometers away from Hargeisa town bordering to Ethiopia.
- The result of the eye examination carried showed that only two children had active trachoma, indicating a very low prevalence of active trachoma of <5% TF (Trachomatous inflammation Follicular) among communities visited by the team. Incidentally many children with severe bulbar type vernal kerato-conjunctivitis (VKC), a case each of Cretinism, exotropia with strabismic amblyopia, Bitot’s spot in the good eye and phthisic bulbi in the second eye most probably from vitamin A deficiency (VAD) were seen in less than a day. Referral of the majority of these cases, we were informed, was near an impossibility because of cost of travel and accommodation.
- The team also observed very encouraging results of Community Lead Total Sanitation (CLTS) activities among people leaving in the three rural communities. Latrines with hand washing facility “tiby tab”are being utilized, water harvesting systems are in place, children have clean faces, fly density is very low and village compounds are clean.
- The Deputy Minister of Health for Somaliland expressed the high commitment of his government and the Ministry of Health to work with partners such as TFHF and Sightsavers and provide all the required support for trachoma (mapping) survey and the training of midlevel eye care professionals.
Manhal Hospital’s Eye Center
- Lecture rooms with audio visual system, good size operating rooms and outpatient facilities are available. Have operating microscopes and a phaco machine. There is ongoing high diploma level ophthalmology 2-year training for general practitioners, 1st batch of 6 students have graduated and the 2nd batch of 5 students are in their 2nd Students do also travel to Pakistan for additional training.
- Local ophthalmologists and the only ophthalmic nurse, Pakistani ophthalmologist and optometrist work in the center.
- The medical director and other eye care professionals working in Manahl hospital reported that trachoma is not a common eye problem among patients visiting both the hospital and other health facilities in the country.
- Trachoma Mapping
- Taakulo to provide the details of village level population and district maps for all the districts located in five regions of Somaliland.
- The Sightsavers Epidemiologist to provide the necessary technical support to Taakulo on sampling and survey methodology.
- Taakulo to finalize the technical proposal for the trachoma mapping survey and submit the survey protocol to WHO for approval through the tropical data website (WWW.tropicaldata.org)
- Taakulo and the Somaliland Ministry of Health to select 17 clinical nurses, 17 recorder trainees and three supervisor trainees to be trained as graders, recorders and supervisors respectively.
- The Somaliland Ministry of Health to write formal request to the Ministry of Health Ethiopia for the latter to provide the necessary support for the training of the trachoma mapping team from Somaliland to travel to Ethiopia and get training on trachoma mapping.
- The Fred Hollows Foundation and Sightsavers International to work with the Ethiopia Federal Ministry of Health and other partners like the Somali Regional Health Bureau, WHO and ITI to organize the training of trachoma mapping team in Ethiopia.
- The training of the trachoma mapping team to be conducted in the Somali Region of Ethiopia in the third week of October 2016. The decision to train in Ethiopia was made because of the low level of active trachoma prevalence observed.
- The trachoma mapping survey to be started and completed between December 2016 and January 2017.
- Taakulo and the Somaliland Ministry of Health to jointly coordinate the field work.
- TFHF to provide all the necessary financial support for the training and the trachoma mapping survey.
- Sightsavers, WHO, ITI and other partners to provide the necessary technical support
- Training of mid-level ophthalmic professionals (MLOP)
- It was agreed that there is a very high need for the training and HR capacity building
- Manhal has suitable staff and facilities for the training of eye health professionals
- Suitable candidates are available
- In the interest of local capacity building and suitability of the center a tripartite agreement (MOU) involving the Somaliland MOH, Taakulo and Manhal is strongly recommended. Therefore, the concerned parties will develop the project plan including budget ASAP to address this acute need.
The scoping visit was successful with its intended plans of meeting leadership of the important partners as well as visiting facilities in Hargeisa town and communities in rural villages. Sufficient evidence on the need for the next steps in addressing both objectives have been gathered. Action points identified should be implemented promptly.
Our sincere appreciations and thanks go to Mr. Omer Jama Farah, his staff and organization for the very impressive facilitation and efficiency. TFHF for supporting the visit.
Health Infrastructure Support Project (HISP) – Providing medical equipment’s, rehabilitation of health facilities, Health Field Camps (visits by health personnel) students exchanges and Doctors
Taakulo Somaliland Community ( TASCO ) has distributed Hospital equipment to Hargeisa Group Hospital and Edna Aden Maternity Hospital. The equipment donated by Australian Doctors for Africa.
Trachoma eye checking by Fred Hollow Foundation
Fred Hollow Foundation are visiting in Somaliland for Trochoma eye problem. Dr. Richard from Australia and Dr. Wondu from Ethiopia are checking Children in Abdaal village on the road to Berbera.
Equipment to Hargaisa Group Hospital and Adna maternity Hospital Donated By Australian Doctors For Africa (ADFA)
Surgical Operation in Hargeisa Group Hospital Conducted and Funded by
Australian Doctors for Africa (ADFA).
Taakulo Somaliland Community (TSC) is a local implementing partner with ADFA