Health service providers in Somalia: their readiness to provide malaria case-management

The adoption into policy since 2004 of new artemisinin-based combination treatments (ACT) for uncomplicated malaria has been almost universal across Africa [1]. However, there have been delays in the deployment of these new, efficacious medicines due to concerns about sustained financing, difficulties in integrating revised recommendations into national standard treatment guidelines and drug procurement and distribution to the periphery of the health sector [2‐8]. Several studies have highlighted inadequacies of the formal public health sector to guarantee appropriate levels of drugs, training and guidelines to all their service providers several years after the introduction of new ACT drugs [7, 9‐11]. These studies serve as a reminder that having recommendations for efficacious drugs does not necessarily translate into a health system prepared to deliver these new medicines to target patients.

Somalia revised its national malaria treatment policy in May 2005, abandoning chloroquine as first-line treatment for uncomplicated malaria in favour of a combination of co-administered artesunate and sulphadoxine-pyrimethamine (AS-SP) [12], which was shown to have an adequate clinical and parasitological response by day 28 of between 95% and 99% across three sites in the country [13]. Quinine was recommended as second-line therapy for treatment failures at both hospitals and Mother and Child Health (MCH) facilities [12]. Diagnosis of malaria was to be undertaken using rapid diagnostic tests (RDT) or microscopy at all health facilities except the lower level health posts where the use of clinical diagnosis and presumptive treatment with SP as first-line therapy was recommended. In case of treatment failure with SP at health posts, patients are to be referred to higher-level facilities for treatment [12].

Civil war has ravaged Somalia for over 19 years causing untold suffering, famine and displacement of its population. In 2000, efforts were made by the international community to support the fragile health system and work toward a reconstruction of this sector to support the health needs of Somali's [14]. This coordinated effort received support from multiple international non-government organizations, bi-lateral agencies and support from the Global Fund for AIDS, TB and Malaria (GFATM) [15]. The Somali Aid Coordinating Body, comprised of development partners, UNICEF, WHO and the three ministries of health representing the three regions of Somalia, applied for support from the GFATM during round 2 and were awarded 12.9 million USD in 2002 to implement a new national malaria strategy [15], including the delivery of AS-SP as first-line treatment.

Very little is known about the current capacities of the public and private sector health services in Somalia and we present here the results of a rapid assessment of the extent, coverage and readiness of services able to provide malaria case-management in three districts.

The availability of public health services was relatively low with only 45 public health facilities and 227 health professionals for approximately 0.6 million people and median distance to health facilities of 6 km. This relatively poor access to health facilities is compounded by the generally bad public transport infrastructure in Somalia. All the health posts (n = 23) were manned by community health workers who had received minimal clinical training. Sixty-two percent of public health facilities prescribed the nationally recommended first-line therapy of AS-SP for hospital and MCH/OP and SP for health posts. Eighty-eight percent of the health facilities that did not comply with the national first-line treatment guidelines were in Gebiley district of Somaliland. Importantly several public health facilities in 2007 were still prescribing chloroquine (38%) as first-line therapy. 67% of public facilities that were compliant with the nationally recommended treatment guidelines did not have the first-line drugs in stock on the day of survey. Diagnosis of malaria using RDT or microscopy was performed routinely over 90% of the public health facilities but only half of these had RDT in stock at the time of survey. Malaria related information such as national treatment guidelines; and RDT wall charts were available respectively in between 60% and 80% of the hospitals and MCH/OP facilities but dosing wall charts for AS-SP and SP monotherapy were available in only 42% of the target public health facilities. The private health sector, although four times larger than public sector in numbers of outlets, had only less than 10% prescribing AS-SP as the first-line therapy and the majority prescribed chloroquine (53%) for this purpose. Interestingly over 30% of private pharmacies provided malaria diagnosis using RDT or microscopy.

Although this study represents the first of its kind in Somalia, there are a number of caveats to the results. First, the study was undertaken in only three purposively sampled districts and may not be nationally representative. The reason for adopting a purposive sample was due the logistical and security implications of undertaking such a study nationally in Somalia. The selected districts, however, represent the relatively more prosperous districts in the three study regions and the equivalent health sector indicators are probably only similar, if not poorer, for other districts. Second, information on training received by the private health sector workers was not recorded. This decision was made following advice by the local health authorities that owners of the many, probably unlicensed, private sector providers would interpret as 'police work' any questions on professional qualification and might have adverse security implications for field workers. Third, due to logistical and time constraints, a proper investigation of the performance of health workers in the public sector, in terms of appropriate diagnosis and treatment of malaria, was not undertaken. As a result, of those facilities that used the recommended anti-malarials, the proportion of health workers who prescribed the appropriate dosage was not recorded. Finally, these surveys and audits were only undertaken once in each district during 2007, as such the results represent only a single snap-shot description of the status of service provision in Somalia. However, these audits are useful exercises to guide areas of policy implementation and could serve, assuming a stabilizing of the security situation, as longitudinal sites to measure progress toward national malaria control effort.

The Somalia national malaria strategy has outlined a series of recommendations for malaria case management including the provision of prompt access to appropriate treatment; provision of relevant information to health workers for appropriate case management; the performance of malaria diagnosis using RDT or microscopy at hospitals and MCH/OPD health facilities; and engagement of the informal sector in the provision of these services [12]. On the basis of the acceptance of the new treatments guidelines two-thirds of the public health sector complied but any practical implementation of the policy was hampered by the widespread shortages in drugs and diagnostic tests. There is need to expand the health services to alleviate the long distances people are likely to walk to access health care given the poor state of public transport; establish efficient systems that can overcome the severe shortages of drugs and diagnostic materials; and improve adherence to recommended diagnosis and prescription through in-service training and job aides notably at the peripheral health posts which serve majority of the rural communities. The national malaria strategy should also be revisited to review the continued use of SP at health posts given that this drug has failed and is no longer in use in most African countries.

The service provider audit highlights the prolific nature of the private health sector in Somalia. This scales with recent findings from a national household sample survey of fevers and their treatment, which documented that over 40% of children who had fever in the two weeks prior to survey sought treatment from the private sector compared to only 8% from the public sector [18]. There is a growing recognition internationally of the role of the private sector in the treatment of malaria [19, 20]. In Somalia the private sector is perhaps more sophisticated than many other settings in Africa, 30% provided a combination of parasitological diagnosis and anti-malarial treatment. However, as with other settings [21] private sector providers continue to prescribe non-recommended malaria treatments. Ministries of health and stakeholders need to create mechanisms to engage, support and regulate the private sector in Somalia. Population distributions in Somaliland and Puntland converge around main roads and intersections where private health service providers are located for market reasons; the less well-served sparsely distributed and remote rural settlements populations require investments in public health sector provision, as these will still remain the main source of care for these communities.