Somaliland is a Sunni Muslim, clan-based society with a large nomadic population and high numbers of internally displaced people (1). It declared independence from Somalia in 1991 but is not yet internationally recognized. It has an estimated population of between two and 3.5 million (2) and remains a fragile state with weak governance, coordination, and infrastructure. The current government health budget is $750,000 per year. Somalia has very high mortality rates (3), but there are no health statistics for Somaliland alone, and mental health is not included in government health indicators (4).A survey in the capital, Hargeisa, indicated that 21% of households care for at least one family member with a severe mental problem (5).
There are only two public inpatient psychiatric units in Somaliland, a ward in Hargeisa Group Hospital (110 beds) and Berbera Mental Hospital (42 beds). Psychiatric staff are auxiliary nurses with limited formal training, and until recently there was no medical input available in either psychiatric inpatient unit other than one general physician available to Berbera Mental Hospital. Conditions are poor in the psychiatric ward of Hargeisa Group Hospital in comparison to the general wards, and it is common for patients there to be chained.
There are no psychiatric staff or psychotropic medications available in general primary or secondary health care services, including maternal and child health centers and other health posts. In addition, Somaliland lacks adequate regulation to safeguard the safety, efficacy, and quality of medicines circulating in the market (6).
Health links are long-term partnerships between institutions in high-income countries and their counterparts in developing countries that aim to improve health services through the reciprocal exchange of skills, knowledge, and experience. The link between King's College Hospital, THET (Tropical Health and Education Trust; an international health charity based in the United Kingdom), and partners in Somaliland has steadily expanded since its inception in 2000.
THET works in partnership with health professionals in developing countries, responding to their requests to help strengthen existing health systems and increase access to health care for those most in need. King's College Hospital is a major teaching hospital in the southeast of London providing regional, national, and international services, training, and education for medical, dental, and nursing students. The early years of the link are described in more detail elsewhere (7).
Today the King's THET Somaliland Partnership (KTSP) involves work in Somaliland with four nurse training institutions, two medical schools, two professional associations, an emerging health professionals council, and some of the public hospitals and regional health boards, as well as ongoing close collaboration with the Ministry of Health and Labour. In general, KTSP focuses on strengthening human resources in Somaliland through training, salary support, mentoring, and support of leadership and governance in training institutions and professional bodies.
The Institute of Psychiatry, King's College London, neighbors King's College Hospital and was invited to join the link in response to requests from Somaliland for mental health input. In addition to working with the agencies mentioned above, the General Assistance and Volunteer Organization (GAVO) is an important part of the mental health component of the link. GAVO is an NGO based in the Somaliland cities of Berbera, Hargeisa, and Burao. GAVO was founded in 1993 with ten volunteers and includes mental health in its work on health and social disadvantage (8). GAVO has supported government capacity in mental health, supported both public mental health inpatient facilities, and has developed pilot community treatment programs in Somaliland.
Information regarding mental health in Somaliland was collected in a survey carried out by GAVO in December 2004. GAVO gathered baseline information regarding mental health and mental health services in order to guide future mental health service interventions. Social workers interviewed a convenience sample of 50 patients, and observers visited both mental health facilities. In addition, 12 doctors, 50 members of the public, and four traditional healers were interviewed.
In 2006 the Hargeisa Regional Health Board in Somaliland asked the KTSP link to expand to include mental health. A further situation appraisal was carried out in 2007 by two psychiatrists accompanied by an expert in public health and the lead clinician of KTSP. The appraisal had a focus on human resources and training for mental health. Questions were formulated in consultation with an international health policy expert (RJ) before the trip. These included determining how mental health is prioritized within the Ministry of Health and Labour; examining mental health-related links within the Ministry of Health and Labour, as well as links between the Ministry of Health and Labour and the ministries responsible for prisons, police, and education; and determining the content of and financial support for the training and continuing professional development of physicians and nurses, the role and organization of pharmacies, the types of health management information systems, and the status of human resource planning. An overarching question was what policy support might be needed in the longer term.
During the appraisal, stakeholder meetings were held with the Ministry of Health and Labour, Hargeisa Regional Health Board, World Food Programme, World Health Organization, and United Nations Development Programme. Systematic information was gathered on the mental health needs, resources, and service provision in Somaliland. In addition focus groups were conducted with and questionnaires were given to groups of medical students, nursing students, and interns.
Mental health has been incorporated into the program of KTSP, which works collaboratively with educational institutions, health service providers, and local NGOs, such as GAVO, to contribute to training and continuing professional development of doctors and nurses. KTSP also works closely with other organizations, seeking to avoid any confusion or overlap of activities. From modest beginnings, the work of KTSP has grown into a multifaceted program that seeks to strengthen the health systems and institutions in Somaliland. KTSP has learned the benefits of a broad approach, both in the range and the geographical spread of the work across the country.
KTSP has included mental health in its support to the two medical and four nursing schools in Somaliland, support that includes equipment and training aids, books, and a small amount of financial resources. Although the first medical students ever to graduate in Somaliland did so without any formal mental health training, with support and visits from KTSP, all 36 final-year medical students and interns in 2008 and all 26 final-year medical students and interns in 2009 received intensive mental health training and rigorous examinations, including written assessments (multiple-choice questions and essays) and clinical assessments (observed structured clinical exams). Mental health has become an intrinsic part of the medical student curriculum, which should have an impact on service provision as the newly trained interns work on the mental health wards.
Graduates of the two medical schools in Somaliland automatically qualify for the Somaliland internship program. The two-year internship program provides a structured training environment and is run by the Somaliland Medical Association and the two medical schools (University of Hargeisa and Amoud University) with support from KTSP. The internship systemrequires that the newly qualified physicians remain within the public sector throughout the internship. During this period they receive salary support from KTSP conditional on their working full-time in the public sector. In 2007 and 2008 a total of 12 medical students from Amoud University entered the internship program. In 2009 the first final-year medical exams for the University of Hargeisa were timed to coincide with the final-year examinations at Amoud University in an effort to harmonize standards through a common examination, which included both clinical exams and a written paper on the topic of mental disorders. In total,36 physicians have now graduated in Somaliland, five have now completed their internship, and four have gone on to specialize atNairobi University in Kenya. The more senior interns have now travelled to the regions of Sanaag, Togdher, and Gabiley, where their presence has contributed to a dramatic increase in demand for service. Mental health is now a part of the internship program, providing regular medical input to mental health wards.
In addition, KTSP has supported the development of the faculties at the two medical schools. In the absence of psychiatrists, two interns (AN and AB) were selected because of their performance and enthusiasm to become KTSP mental health representatives for each of the two medical schools. They became examiners for psychiatry in the final-year medical exams and are involved in the mental health training of medical students and nurse-tutor students (nurses who are being trained to teach student nurses and deliver continuing professional development to nurses) with the continued support of KTSP. In addition the representatives have become active in advocating for mental health and its position in the intern program, developing forms for documentation on the ward and managing improvements on the psychiatric ward. This has been so successful that another two representatives have been selected competitively.
In response to the need to raise the standard of nursing care, a training program for nurse tutors was established to strengthen the long-term capacity of the nurse training institutions. During the revision of the national nursing curriculum, mental health was incorporated drawing on curricula from Kenya and elsewhere (9). The 26 nurse-tutor students have received mental health training provided by an experienced U.K. psychiatrist and other KTSP mental health representatives to teach mental health in basic nurse training and continuing professional development. KTSP has also provided training for two weeks for Hargeisa Group Hospital inpatient nursing staff by a Somali-speaking psychiatrist.
As part of its efforts to support the development of an increasingly professional workforce, KTSP is working with the Somaliland Medical Association and the Somaliland Nursing and Midwifery Association. Salary support for key personnel has provided a vital boost to the development of these professional associations, enabling them to move forward with the implementation of their first strategic plans. In addition, support is being provided to the emerging National Health Professionals Council, which, in the long term, will play a key role in the accreditation, licensing, and regulation of health personnel and should have a profound effect on the private as well as the public health sector.
Important factors in forming this collaborative relationship have been respectful communication, a shared vision, and most important, recognizing the work as a joint venture. Effective collaboration ensures that local partners have a strong sense of ownership from the outset. After requests from Somaliland, mental health activities have been taken up with enthusiasm on the basis of extended dialogue and meetings with local stakeholders, enabling the work and its timing to be as useful as possible in Somaliland.
This multipronged approach to strengthening the health sector—including support to institutions and professional associations and salary support—has, in our view, enabled the new generation of health workers, who have mental health skills, to stay in the public sector rather than moving into the private sector. In time, this will have an impact on rural-urban disparities, as the increasing numbers of interns and nurse tutors are deployed. It will also mean that the large numbers of persons with mental illness who have never received specialist care should benefit from the incorporation of mental health training into the training of general nurses and physicians who will have an understanding of diagnosis and basic management of psychiatric disorders.
The support to Somaliland has thus far resulted in increased knowledge of mental health among nurses and physicians in training and the development of a mental health faculty. In building this partnership we have learned the importance of continuous dialogue, so that we can be led by our partners in working together to develop a shared vision, embedding mental health into the health sector and strengthening the health sector by using a multipronged approach.
Continued work requires more policy dialogue and integration of mental health into efforts to strengthen the overall health sector. This is especially the case in training for maternal and child health centers and health posts, liaison with traditional healers to reduce harmful practices (ideally in the context of a government regulatory system of private health care), and integration into other sectors, including prisons and schools.
The authors acknowledge the work of Yasin A. Abdi, M.B.Ch.B., Maryam Hassan Dahir, Sakin Jirdeh, Deria I. Ereg, M.D., Sacad A. Walhad, M.Sc., Roda Ali, B.S.N., Andrew Leather, F.R.C.S., Susannah Whitwell, M.R.C.Psych., Rachael Coker, M.A., and Aden Ismail, M.D.
The authors report no competing interests.