Somalia: Health Inequities
Health inequality is a major problem throughout global health. Disparities within access to healthcare due to factors such as socioeconomic status, place of residence, and race can cause significant differences in health outcomes between people. Somalia ranks to be one of the most dangerous places for maternal health in terms of childbirth and has high maternal mortality rates. Skilled birth attendants (SBA) are integral to ensuring maternal health during delivery, although there is uneven access to these skilled professionals between urban and rural areas in Somalia, causing disparity within the population. In recent years, there have been many organizations reaching out to provide humanitarian aid through program developments. In order to further understand the issue in Somalia, the WHO tool was used to first analyze the percentage of SBA’s within Somalia’s urban and rural areas. The same was then done for a neighboring country and a high SDI country. In order to further analyze the health outcomes associated with access to SBA’s, the GBD tool was used to determine the DALY rates per 100,000 in terms of maternal disorders attributable for all risks. Somalia was compared to a neighboring country and a high SDI (socio-demographic index) country in order to understand the different dynamics of the countries. The high SDI country’s DALY rates were much lower than Somalia’s and the neighboring country. This is due to a better healthcare system and infrastructure within the country. The neighboring country had slightly lower DALYs than Somalia, due to more stability within the neighboring country’s government. The question arises on what policies to implement in order to help improve the situation in Somalia. Somalia has come a long way in terms of healthcare access, but much improvement is still needed.
When discussing global health, health inequality and inequity (disparities) are two important concepts to understand. Health inequality comprises any general variation in measurable aspects of health between individuals. Health inequity, however, is a type of health inequality that focuses on the differences in health between individuals that are unjust. These are differences in which one individual may have inferior health outcomes than another due to situations that the individuals are not able control 1 . Health inequity can be caused by a person’s community and social environment. Examples of conditions that can cause unequal health outcomes are racial backgrounds and socioeconomic statuses of people as these cause variations in the amount of access to healthcare. The general drive to reduce these health inequities between individuals is the moral belief that everyone, despite their backgrounds, has the right to access proper healthcare.
A major global health inequity is uneven access to a skilled birth attendant (SBA) to assist a mother during labor and delivery. An SBA is defined to be a certified health professional such as a doctor, nurse, or midwife who has been educated to possess the skills necessary to manage uncomplicated pregnancies, childbirth, and to be able to identify and manage any complications to the mother and newborn 20. Having skilled health personnel during birth can improve the health outcome for the mother during childbirth as they are trained to prevent most obstetric complications. Of the many health statistics, maternal mortality rates show the greatest disparity between the developing and the developed world. More than 99% of maternal deaths occur in the poorer countries; many are because of pregnancy related complications. Without proper guidance during labor and birth, women can face harmful circumstances that can lead to death, such as sepsis, haemorrhage, eclampsia, obstructed labour and unsafe abortion. These complications can be significantly prevented if the women had the access to a SBA. As the SBA would possess the skills and knowledge to prevent or reduce these health issues 3.
Somali women are one of the most high-risk groups worldwide in terms of maternal mortality. Somalia has faced years of conflict which have resulted in basic facilities such as maternal and child health facilities and services to have been damaged or significantly limited access 6. The country is also very poor and has one of the lowest per capita income in the world. Since 1991, Somalia has been without a nationally recognized central government and since then has been in a state of civil war. Over the last two decades, the ongoing civil war destroyed all of the healthcare and economic infrastructure within the country 11. The turmoil and political conflict has also caused increased restriction to access to humanitarian assistance such as trained health personnel during childbirth 12.
Individuals in Somalia have also shown to have different health outcomes in relation to maternal health based on their place of residence, mainly between urban areas vs rural areas. This is due to the differing amount of access to skilled health personnel during birth that these two areas have. This unequal distribution of access to a skilled health personnel based on place of residence is a health inequity as it is unfair and preventable. Rural areas within the country face more issues with maternal health and have less access to skilled health personnel during birth than individuals located in more urban areas. One out of every 12 women dies because of pregnancy-related causes due to child deliveries that are conducted in the absence of a skilled birth attendant and difficulty accessing health facilities, especially in the rural populations 21. Only around a third of women giving birth have a skilled personnel assisting them in the country and in the rural areas this number is much lower 16. In the most rural villages, traditional birth attendants handle all of the birth deliveries since they have limited access to healthcare services. The traditional birth attendants usually work under unsanitary conditions and don’t usually have the knowledge to deal with any complications that can arise while giving birth 2 .
As highlighted previously, the Somali government is unstable and with the numerous issues already plaguing the country, maternal health during childbirth has not been given the amount of attention it needs. In order to combat this issue, however, Somalia has been receiving foreign aid and humanitarian assistance through programs designed to reduce the health inequity and improve maternal health. Organizations such as UNICEF and partners supported by the European Commission have worked towards creating a program to increase maternal health. Starting around 2013, the program renovated 14 maternal and child health centers to basic emergency obstetric and neonatal care facilities. These upgraded maternal and child health clinics have allowed for skilled personnels to access, monitor, and take care of pregnant women 16 . The World Health Organization and other United Nations partners have been working in Somalia to create a method to ensure that Somali mothers can have equal access to health services across urban and rural areas within the country. This plan is called the “Reproductive, maternal, neonatal, child, and adolescent health strategic plan” and focuses on using the universal health coverage model. This model works to ensure that health is equitable to all regardless of an individual’s social determinants of health such as place of residence 20. The American Refugee Committee International has also been working with the Somali health sector since 2011 and has been operating mobile and stagnant health facilities. Their main goal is to find the gaps in healthcare in the country and fill them in, especially the differences between the access of healthcare between rural and urban areas 2. Although much help as been given, Somalia still ranks high for maternal mortality due to childbirth and will need to take further action to combat the issue.
In order to assess the extent of the disparity based on place of residence, urban vs rural areas, within the country, I used the World Health Organization’s Global Health Observatory visualization tool 8 . The indicator chosen was ‘births attended by skilled health personnel (in the two or three years preceding the survey) (%)’ and the dimension was ‘place of residence’. In 2006, the rural area comprised of 63.3% of the total Somali population, while only 14.5% of them were attended by skilled health personnel during birth (Figure 1). During the same year, 36.7% of the population was located urban areas and 65% of them were attended by skilled health personnel during birth (Figure 2). The median for the global national average for the percent of births attended by skilled health personnel (in the two or three years preceding the survey) was last recorded to be 83.8%. Somalia, in 2006, had a percentage of 33.0% (Figure 4). Kenya, a neighboring country, had 44.7% last recorded in 2008 (Figure 3). Barbados, a SDI country, had 98.9% (Figure 5). Kenya, neighboring country, in the rural area (81.1% of the population) 37.6% of births were attended by skilled health personnel (Figure 8) . In the urban area (18.9% of the population) 75.3% were attended (Figure 9) . In Barbados, a high SDI country, in the rural areas (37.1% of the population) 100% of births were attended by skilled health personnel. In the urban areas (62.9% of population) 98.3% of the births were attended.
In order to further understand the disparity and maternal disorder health outcomes, I used the GBD visualization tool 7. Over the time period of 1990–2017, Somalia had the highest DALY rate per 100,000 for maternal disorders attributable to all risk factors, but was decreasing to a great degree over the years. Kenya, neighboring country, had a steadier decrease over the years and was in the middle for DALY rates. Barbados, high SDI country, had very low daly rates over time and also a steady one. For 1990, Somalia’s DALY rate was 1139.61 per 100,000 compared to 2017 which was 609.03 per 100,000. For Kenya in 1990, it was 492.07 per 100,000 compared to 2017 which was 234.38 per 100,000. For Barbados in 1990, it was 26.92 per 100,000 compared to 2017 which was 18.32 per 100,000 (Figure 6). These differences in DALY rates are also demonstrated for 2017 in figure 7.
When measuring the health inequity within the country, it was no surprise that although the population in the rural areas was larger (63.3%) only a small portion of them were attended by skilled health personnel. In the urban areas, there was a small population (36.7%), but a larger portion of them were attended by skilled health personnel. This unfair distribution indicates the extent to which the disparity based on place of residence exists within the country. Most of the access to skilled health personnel are situated within the urban region, while the rural areas tend to struggle to gain the same equal access. With the political conflict in the country, there was also a food shortage crisis, causing many people to disperse and to also situate themselves into cities and towns, causing most of the healthcare access to be situated in urban areas 13 . The national average for births attended by skilled health personnel was significantly lower for Somalia compared to the global median, indicating that on a global scale, Somalia is doing very poorly.
The results indicate that the DALYs per 100,000 for maternal disorders in Somalia is still very high. As mentioned above, the state of political conflict and the civil war that occurred within Somalia had blocked much of healthcare access in Somalia and has caused restricted access to humanitarian aid. This restriction also means the limited access to skilled health personnel during childbirth for mothers 9. Although the high DALY rate, there is a gradual decline (a positive trend) in the number of DALYs per 100,000 of maternal disorders attributable to all risks between the years 1990–2017 for Somalia. This decline can be attributed to the increased outreach and humanitarian aid discussed earlier by organizations such as UNICEF and EU that have been providing more skilled health personnel to assist with childbirth. Also in 2011, the Republic of Somalia was restored and the ministry of health has been trying to rebuild the broken healthcare system amidst the chaos 13 .
Kenya’s national average for births attended by skilled health personnel was also significantly lower than the global median just like Somalia. In terms of health in equity based on place of residence, Kenya showed similar results as Somalia. The country has more births attended by skilled health personnel in the urban areas than the rural even though more people resided in the rural areas. Similar to Somalia, Kenya also faces social and economic inequalities. There is a major divide in the access to health care within the country between the rural and urban communities, rural communities struggle more to gain access 18 . Kenya also faces a shortage in healthcare professionals and they are poorly distributed throughout the country, this leads to low-quality treatment in remote regions. The poor wages in the rural areas, ill-equipped facilities leads to an understaffing of the skilled health personnel in remote areas 5.
When comparing Somalia to Kenya, Kenya’s GBD indicated slightly lower DALYs per 100,000 of maternal disorders attributable to and a much less dramatic decrease than Somalia’s over the years. Since the country’s independence, Kenya has been making progress in infrastructure and healthcare. The Kenyan government, in 2008 launched a long-term development plan Vision 2030 which aims to ensure better healthcare access and service to all citizens 14. The lower DALY rate can thus be due to the better governmental infrastructure and regulation that Kenya has compared to Somalia. Unlike Somalia, Kenya has not gone through as much political turmoil. The DALY rates were only slightly lower than Somalia’s due to the fact that although Kenya has more stability, the country is still poverty stricken thus limiting the amount of access many have to healthcare.
As the results indicate, Barbados has significantly lower DALY rates over the years and is also very constant. The country is also doing significantly better than the global national average for percent of skilled attendants in childbirth. In terms of health inequity between urban and rural, there is no health disparity shown for births attended by skilled health personnel based on place of residence in the country. Urban and rural areas had almost all of their births attended by skilled health personnel. This makes sense as Barbados being a high SDI country has better healthcare infrastructure and actively works towards ensuring equal access to all citizens. Being an island, the country also has a lower population to take care of adding to the easier accessibility 10.
Although there are many humanitarian aid and programs being implemented within Somalia, there is still much progress to be made. There are two main policy implementations to be made in order to increase access and improve maternal health during childbirth. The first policy recommendation is to increase the number of staffing of skilled birth attendants in the rural communities’ clinics by providing incentives such as increased financial profit and/or better healthcare infrastructure in clinics. Currently, humanitarian aid has allowed SBA’s to travel to rural regions to provide healthcare services, but there is still a shortage within the remote areas. Increasing the number of staffing by providing an incentive, doesn’t necessarily have to be only monetary, will greatly reduce the level of disparity 15 . The second policy implementation is to train more traditional birth attendants to become more educated in maternal health and become more skilled with childbirth. Since traditional birth attendants are already on duty to assist with childbirth, providing more education for them can help increase knowledge in maternal health and can help reduce the health outcomes associated with the disparity 4.
Somalia has, unfortunately, been struggling with issues such as access to healthcare, food insecurity, and water, sanitation and hygiene due to political conflict and unfortunate circumstances. Over the years, however, the country has shown promising results. With increasing political stability and humanitarian aid, Somalia will surely become a healthy, secure nation in the years to come.
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Figure 1. Percentage of births attended by skilled health personnel in rural areas of Somalia
Figure 2. Percentage of births attended by skilled health personnel in urban areas of Somalia
Figure 3. National average of births attended by skilled health personnel in Kenya (neighboring country) in 2008
Figure 4. National average of births attended by skilled health personnel in Somalia (2006)
Figure 5. National average of births attended by skilled health personnel in Barbados (high SDI country)
Figure 6. Maternal disorders attributable to all risk factors for Barbados, Kenya, and Somalia between the years 1990–2017
Figure 7. DALYs per 100,000 for maternal disorders attributable to all risk factors
Figure 8. Percentage of births attended by skilled health personnel in rural areas of Kenya
Figure 9. Percentage of births attended by skilled health personnel in urban areas of Kenya