In Somalia, a Healthy Commitment

	Residents of Qarhis have made the health clinic a community priority.

January 10, 2005—Priya Gajraj has no doubt about the dedication of the local community in Qarhis, in the Puntland,  Somalia, to keep their health clinic in operation.

Beginning in 2002, the clinic was shut off from the outside world for more than a year—a victim of local fighting.

And for that long year, Priya Gajraj, the World Bank's country officer for Somalia, says the local community kept the doors of its health clinic open—without outside international assistance.

Somalia has been described as the quintessential failed state. It's a country which has been wracked by civil war—with the nation split among clan-based militias since the fall of the regime of Major General Mohamed Siad Barre in 1991.

There was no fully functional national government in Somalia for more than a decade. A peace process now underway has resulted in the establishment of a new parliament and the election of a new president and prime minister. 

The years of civil war have exacted a severe toll. Indicators suggest health standards in Somalia are among the worst in Africa. Life expectancy is 47 years—one of the lowest in the world. Nearly one quarter of all children die before they reach their fifth birthday.

It was against that background, the World Bank became involved since 2000 in efforts to improve community health services in Somalia with funding from the Bank's Post-Conflict Fund.

With no national government in place, the World Bank joined forces with the Somalia Red Crescent Society and the International Federation of Red Cross/Red Crescent Societies to fund health centers in Puntland and Somaliland.

"The Somalia Red Crescent Society was one of the only remaining institutions operating throughout the country after the collapse of the government, "  says Gajraj.

According to Sarah Cliffe, head of the Bank's LICUS (Low Income Country Under Stress) unit, the health project represents a clear example of the Bank working with the non-government sector to improve the lives of those in difficult environments.

Outpost of Hope

Patients are able to receive basic curative care, using essential drugs, as well as antenatal and postnatal care and immunization services.

It's a health clinic that comes not only with a clinic and laboratory, but also with an enclosure so visitors to the clinic can house their livestock.

"This is a pastoral nomadic community. Many patients, with their livestock, travel from far distances in Somalia and also from the border area with Ethiopia, " Gajraj says.

Without a health clinic, local people use traditional healers, or resort to private pharmacies where expired or inappriate drugs are often sold.

Gajraj says the aim was to build community ownership of the project - a feat that's being achieved.

"In the last three years, the community has put in 15% of the running costs of the services," she says. "That shows it's a service they value and they've demonstrated their high level of commitment to the project."

A review of the project conducted for the World Bank through the International Red Cross has found the project successfully improved the health condition of the most vulnerable - women and children - as well as men and the elderly, living close to the clinics.

The people received basic curative care, using essential drugs, as well as antenatal and postnatal care and immunization services.

The review says the "project impacted positively on the lives of the communities. It reduced mistrust of the health system, thereby motivating people to come for consultation, antenatal and postnatal care and treat. The health education caused a decline in the incidence of diarrhoeal diseases."
Gajraj says the intention now is to use the clinics as a model to replicate, adapting it to local context.

And in another venture in Somalia, the World Bank is seeking to work with local communities to provide support on animal health services at the community level.

Healthy Animals Equal Healthier Economy

The World Bank's Country Re-Engagement Strategy for Somalia, which was approved by the Bank's board of directors in 2003, cites livestock as an area for strategic intervention in the country.

Country Director Makhtar Diop describes livestock as central to Somali culture and incomes. Livestock remains the main source of Somalia livelihoods, making up 80% of exports in normal years.

But livestock exports from Somalia have periodically been interrupted by bans imposed by importing countries in the Gulf region, due to outbreaks of livestock disease.

In partnership with the European Commission and Food and Agriculture Organization (FAO), World Bank support has led to the preparation of a longer term livestock strategy for Somalia as a framework for further coordinated work in the sector.

The World Bank is currently supporting a livestock certification program for Somalia - to seek to build a livestock board to develop standards for inspection and certification of livestock. 

Gajraj says the latest plans are based on the same philosophy of working with the communities—but in this case to provide support to animal health services in Puntland. 

It's an area where people are suffering from the combined effects of the livestock ban, four years of drought, and overexploitation of natural resources. The livestock ban has had a devastating impact on Somali pastoral livelihoods—which have been highly dependent on the market of Saudi Arabia for 95% of their total livestock export.

Gajraj says there's a clear need to improve animal health in rural areas as most veterinarians are located in urban areas.  There are also frequent inter-clan conflicts over grazing land - as the traditional clan system has become politicized since the civil war.

The aims of the latest project are for the Bank to work with CARE Somalia and VSF - Suisse in increase access to essential animal health services for pastoral communities and improve understanding and consensus on natural resource management needs.