Somalia continues to suffer from a chronic humanitarian crisis resulting from persistent conflicts and natural disasters. Almost half of Somalia’s population of 6.8 million live in poverty. Maternal and infant mortality rates – estimated at 1600 per 100,000 and 132 per 1000, respectively – are among the highest in the world.

The Puntland state of Somalia, in the northeast of the country, declared its autonomy in 1998. Puntland does not seek independence from Somalia, but has established its own government. According to the Ministry of Health, 25% of women die within 33 months of their first pregnancy. Most women do not have access to medical facilities, and are assisted in childbirth by traditional birth attendants. The quality of health services is poor, healthcare providers lack basic skills, and progress is undermined by the lack of a coherent management system. Women, adolescents and children face a multitude of health risks, reflecting their inferior social position. Some harmful practices, including female genital mutilation, are deeply embedded in the local culture.

Maternal healthcare

In 1992, with funding from the Netherlands government, CARE launched the Puntland Health Partnership Programme in order to improve access to quality maternal healthcare for 22,000 women in two regions, Nugal and Mudug. CARE is working in partnership with four women’s NGOs, two hospitals, four health posts and three mother/child health centres.

Because of its weak resource base, the ministry has been unable to provide basic healthcare to its population. Local NGOs and community organisations have therefore emerged to fill the gap, and are now playing a more prominent role in developing basic health services. The ministry and CARE are supporting these organisations, especially women’s NGOs, using a partnership approach to encourage their self-reliance and their ability to help themselves.

In order to reduce maternal and infant mortality rates in Nugal and Mudug – the partners first organised training for traditional birth attendants and community health workers, and management courses for community development committees to improve the running of the health posts. The partners are also involved in constructing, rehabilitating and equipping the health posts, and are supporting urban hospitals by improving buildings, equipment and management systems, and training in obstetrics and gynaecology for doctors and nurses. Other activities include raising awareness through radio broadcasts, discussion meetings, mobilisation campaigns, and even poetry.

Positive changes

Many positive changes are already apparent. Even people in remote rural areas now have access to community health posts, and the quality of care they provide has improved, now that health workers and birth assistants have the skills they need to help pregnant women. Villagers are increasingly involved in the management of community-based healthcare, and are more aware of critical aspects of maternal and child health, including the risks posed by HIV/Aids. Urban hospitals are better equipped, and one has introduced new services, including caesarean sections, vacuum extraction and ultrasound scans.

These results could not have been achieved without the partnership. Since local organisations are part of rural communities, the programme has focused on building their self-esteem and capacities. In the process, many lessons about partnerships have been learned.

• Shared values are a prerequisite for building positive working relationships and for resolving the differences that inevitably arise.
• Continuous efforts have to be made to include marginalised groups such as women and youth in decision making about project activities.
• Within any organisation, internal good governance will create an enabling environment for participatory decision making with communities. A functional board of directors is crucial for ensuring accountability, both externally and internally.
• Funding organisations should remain conscious of their power and influence on the partners, and what this means for any partnership.
• The distribution of roles and responsibilities should be based on an assessment of the strengths and weaknesses of each of the partners.
• Adequate time should be allowed for relationships to develop. Consensus building should be at the heart of any partnership approach, however time consuming it may be.

Links

CARE Nederland

CARE Somalia

Puntland State of Somalia

Puntland Health Partnership Program

UNICEF Statistics: estimates of maternal and infant mortality