Somalia: Wholly inadequate Covid-19 response highlights need to use debt relief to invest in healthcare

The Covid-19 pandemic has highlighted the need to urgently address the serious and longstanding issues facing Somalia’s healthcare system following years of underinvestment and against a backdrop of crippling debt, Amnesty International said in a new report published today.

The report entitled “We Just Watched Covid-19 Patients Die” – Covid-19 Exposed Somalia’s Weak Healthcare System But Debt Relief Can Transform It, shows how Covid-19 has exposed a range of pre-existing weaknesses in Somalia’s healthcare system.

It is based on interviews with more than 40 individuals, including 33 health and humanitarian workers, government officials, finance and debt relief experts, as well as analysis of government budgets and policies and feedback from Somalia’s Ministry of Finance.

The research finds that access to health facilities for Covid-19 patients has been severely limited with just one hospital in the capital Mogadishu managing all Covid-19-related cases across the south-central region during the first wave of infections.

“The Somalia government’s response to the pandemic was wholly inadequate – characterized by a dire lack of ventilators, severe shortages of oxygen and almost non-existent access to ambulance services, all of which are the result of years of neglect and failure to invest in healthcare” said Deprose Muchena, Amnesty International’s Director for East and Southern Africa.

“Now that Somalia is eligible for debt relief, the authorities should ensure that a sufficient portion of the proceeds and future grants are used to significantly invest in improving healthcare provision, both in rural and urban areas.”

Poor healthcare infrastructure and little investment

Somalia, whose recent history is marked by armed conflict and political instability, as well as being one of the most heavily indebted countries in the world trails others on many health indicators, including access to reproductive, maternal and child healthcare. Child mortality is currently the highest in the world. In 2017, it had a ratio of one surgeon per 1,000,000 people. Only an estimated 15 percent of people have access to medical care in rural areas.

An Amnesty International analysis of the country’s government budgets between 2017 and 2021 showed that the average budget allocated for health and health-related projects was only 2%. In the same period, the average budget allocated to the security sector, including to the ministries of defence and internal security, was 31 percent of the total government budget.

Wholly inadequate response to Covid-19 and health workers under threat

Officially, there have been 15,294 confirmed Covid-19 cases, and 798 confirmed deaths, but the actual figures are likely to be much higher given the limited testing capacity, and weaknesses in the reporting and registration of deaths.

This is confirmed by the country’s Chief Medical Officer Dr. Mohamed Mohamud Ali, who told Amnesty International that he believes the death toll from Covid-19 is far higher than estimated. “Testing was very limited. Only those who managed to get to health facilities and were tested are included in the official government data. The figure is just a tip of the iceberg, many more were infected and died at home,” he said.

Medical staff Amnesty spoke to reveal how the country has struggled from day one with its healthcare response during the pandemic. One nurse told Amnesty International: “We scrambled at the beginning. Everything was a mess. We had nothing to treat patients with. There was no oxygen, no ICU beds, and no ventilators. We just watched patients die, it was really sad.”

A senior doctor said many Covid-19 positive patients also died because of insufficient oxygen supplies: “We had to use a single nasal oxygen cannula for multiple patients. There was a day we had four elderly men in one ward, they all needed oxygen, but they all died within 10 minutes. I can still remember their faces; I am sad we were unable to get oxygen to save their lives.”

Commenting on shortages experienced during the first few weeks of March 2020, a lab specialist with the Ministry of Health told Amnesty International: “We did not have any testing equipment for a few weeks… We were initially sending samples to Kenya for testing until we got the first PCR machine as a donation from the Chinese company Alibaba.”

To make matters worse, health workers have had to  work in a challenging and often highly dangerous security environment. For example, in Gololey village, Middle Shabelle region, eight health workers at a mother and child clinic were abducted and killed by armed men dressed in military and police uniforms in May 2020. Authorities appointed a committee to investigate the incident, but to date the findings have not  been made public and no perpetrators brought to justice.

Currently, the country is faced with a shortage of vaccines, giving it little fighting chance against the continued spread of Covid-19. By early August, only 0.6 percent of the population was fully vaccinated. Of the 33 health workers Amnesty International interviewed for this report, although all had had the opportunity to be vaccinated, 19 of them had it turned down – a situation emblematic of the wider vaccine hesitancy in the country, the result in part, of a lack of sufficient public information.

Debt relief as an additional resource: an opportunity that must not be squandered

Despite these challenges, the government, with the help of international partners such as  the World Health Organization, has been making efforts to strengthen the health system, including the adoption of a roadmap towards Universal Health Coverage (UHC). The government must continue to build on these efforts.

However, a key window of opportunity for significant additional resourcing has opened up which the government must seize. Somalia  recently reached the decision point for debt relief under the Heavily Indebted Poor Countries (HIPC) Initiative. This means it is also now eligible for additional budget support and grant financing.

Amnesty International is calling on the Federal Government of Somalia to allocate a sufficient portion of any debt relief proceeds and new grants to improving the right to health, in line with its UHC roadmap and its international human rights obligations. To ensure adequate healthcare for all both the government and the international community, with financial and technical assistance, have a role to play.

“COVID-19 has caused the death of millions across the world, but the sad truth is that in Somalia so many of those deaths were preventable. The country cannot afford to keep repeating these failings. The government should use any gains from debt relief to significantly and progressively increase health budgets from the 2% pre-Covid-19 allocation with the aim of  ultimately hitting the 15% of annual budget in line with the Abuja Declaration, which it has signed up to,” said Deprose Muchena.

“Somali people have the right to access adequate health facilities wherever they live across the country, including critical health care and treatment which continues to be desperately needed in the fight against Covid-19.”