Fragile states need essential national health research: the case of Somalia
Authors: Khalif Bile, Marian Warsame, Abdifatah Dirie Ahmed
Journal: The Lancet Global Health (2022)

Constituted on July 1, 1960, Somalia inherited a weak post-colonial, health-care system based on curing disease rather than preventing it, with most rural and nomadic populations having negligible access to essential health-care services. The next three decades resulted in notable improvements through expansion of health facilities and mobile outreach services. In the 1970s, academic institutions upscaled their training of health-care providers, who were then deployed as across the health-care system. During the same period, many senior Somali medical doctors underwent postgraduate studies at Italian universities and, after returning, engaged in academic teaching, training doctors, nurses, midwives, and a range of other health workers. Another milestone in building research capacity was the Swedish Government's support in the 1980s to the Somali National University, Mogadishu, Somalia, enabling the successful training of 23 Somali faculty members on master's or doctoral programmes at Swedish universities. The civil war, which broke out in the 1990s, led to tragic disruptions to the health system in the long term, due to a protracted complex emergency accompanied by famines and population displacement. The transition to recovery of health-system organisation, regulation, and workforce development began in the 2010s with the institution of a transitional federal government, creating opportunities to initiate the pursuit of universal health coverage (UHC). During this recovery phase, around 25 academic institutions with undergraduate medical or health courses and a few master's training courses were operationalised, and steps were taken to revive collaboration with Swedish universities.1Somali–Swedish Action Group for Health Research and DevelopmentHealing the health system after civil unrest.Glob Health Action. 2015; 827381Crossref Scopus (3) Google Scholar, 2Dalmar AA Hussein AS Walhad SA et al.Rebuilding research capacity in fragile states: the case of a Somali–Swedish global health initiative.Glob Health Action. 2017; 101348693Crossref PubMed Scopus (10) Google Scholar The Puntland Ministry of Health hosted the First National Institute of Health (NIH) Health Research Conference—Laying the Foundation for Health Research in Somalia in Garowe, Somalia, from Jan 30–Feb 1, 2022, which was organised by the Somali NIH and Federal Ministry of Health in collaboration with WHO, the Alliance for Health Policy and Systems Research, the Public Health Agency of Sweden, the African Field Epidemiology Network, Somali universities, the Somali–Swedish Research Cooperation Initiative, and the Somali Swedish Researchers' Association. This partnership placed health research at the forefront to accelerate progress towards UHC and the Sustainable Development Goals, on the basis of the conviction that the development of health research capacity has a key role in fragile states for rebuilding national health services and academic institutions.2Dalmar AA Hussein AS Walhad SA et al.Rebuilding research capacity in fragile states: the case of a Somali–Swedish global health initiative.Glob Health Action. 2017; 101348693Crossref PubMed Scopus (10) Google Scholar The conference brought together 183 participants, who presented 50 selected abstracts and delivered 15 panel presentations covering all aspects of the health system, focusing on the essential package of health services, research priorities, ethical guidelines, training, partnerships, and human resources for health. The presentations also included a bibliometric review of Somali health research spanning from 1945 to 2020. The conference provided an excellent opportunity to bring together young Somali researchers, health professionals, and scholars along with senior academicians and research mentors from partner institutions collaborating with the Somali nationals in organising the conference. It brought attention to the need for improvement in health research capacity of indigenous Somali institutions, replacing the exclusive dependence on foreign researchers in designing, implementing, analysing, and publishing research results.2Dalmar AA Hussein AS Walhad SA et al.Rebuilding research capacity in fragile states: the case of a Somali–Swedish global health initiative.Glob Health Action. 2017; 101348693Crossref PubMed Scopus (10) Google Scholar, 3Mutapi F Africa should set its own health-research agenda.Nature. 2019; 575: 567Crossref PubMed Scopus (4) Google Scholar, 4Rahman MM Ghoshal UC Ragunath K et al.Biomedical research in developing countries: opportunities, methods, and challenges.Indian J Gastroenterol. 2020; 39: 292-302Crossref PubMed Scopus (7) Google Scholar Participants were fully confident in their collective resolve to strengthen the link between evidence generation and primary health-care implementation to accelerate progress towards UHC and the Sustainable Development Goals. The Somali Health Action Journal, established in collaboration between Somali and Swedish universities to offer an open access dissemination platform, was also introduced during this conference.5Mohamud KB Somali Health Action Journal–a collaborative venture for health research and development.Somali Health Action J. 2021; (published online Oct 25.)https://doi.org/10.36368/shaj.v1i1.262Crossref Google Scholar A bibliometric review paper reflected the need for strengthening research capacity and provided a rationale for creating the Somali Health Action Journal digital platform.6Mohamud KB Emmelin M Freij L et al.Who published what on Somali health issues? Forming the policy for SHAJ through a bibliometric study.Somali Health Action J. 2022; (published online Jan 13.)https://doi.org/10.36368/shaj.v2i1.281Google Scholar The journal is building collaborative partnerships with focus on Somali priority health needs, promoting research capacity across the health system, and encouraging the publication of articles by Somali researchers. The Somali Health Action Journal will enhance its relevance by addressing Somali health challenges and linking with national and regional research agendas.3Mutapi F Africa should set its own health-research agenda.Nature. 2019; 575: 567Crossref PubMed Scopus (4) Google Scholar The journal will promote Somali research ownership, including in terms of cofinancing research. The challenges emphasised during the conference included the scarce opportunity for research training, little funding, and fragmentation between academic institutions and health services. All stakeholders stressed their commitments to bridging the context–knowledge gap and to directing research funding to in-country activities of building research capacity.3Mutapi F Africa should set its own health-research agenda.Nature. 2019; 575: 567Crossref PubMed Scopus (4) Google Scholar, 4Rahman MM Ghoshal UC Ragunath K et al.Biomedical research in developing countries: opportunities, methods, and challenges.Indian J Gastroenterol. 2020; 39: 292-302Crossref PubMed Scopus (7) Google Scholar To mitigate the context–knowledge gap, it was recommended that the Somali federal and state governments allocate a minimum of 2% of their national health expenditures and 5% of the domestic and donor health financing to health research and building capacity for research, focusing on interventions with large effects, such as expanding the coverage of maternal and child health services. Somali universities were requested to embed research in their faculty's career development through master's and doctoral programmes that are crucial for the development and retention of local academicians.7Uzochukwu B Onwujekwe O Mbachu C et al.The challenge of bridging the gap between researchers and policy makers: experiences of a health policy research group in engaging policy makers to support evidence informed policy making in Nigeria.Global Health. 2016; 12: 67Crossref PubMed Scopus (59) Google Scholar Somali universities and health-system professionals were encouraged to support the Somali Health Action Journal's catalytic role in promoting research as a method for knowledge sharing for policy and practice.7Uzochukwu B Onwujekwe O Mbachu C et al.The challenge of bridging the gap between researchers and policy makers: experiences of a health policy research group in engaging policy makers to support evidence informed policy making in Nigeria.Global Health. 2016; 12: 67Crossref PubMed Scopus (59) Google Scholar, 8Wall S Emmelin M Krantz I et al.Global health action at 15—revisiting its rationale.Glob Health Action. 2021; 141965863Crossref PubMed Scopus (1) Google Scholar We believe that collaborative research based within the country is a method for improving the Somali health system after an era of civil unrest and deteriorating resources.1Somali–Swedish Action Group for Health Research and DevelopmentHealing the health system after civil unrest.Glob Health Action. 2015; 827381Crossref Scopus (3) Google Scholar We see the NIH research conference in Garowe as an important and promising first step to engage universities in building capacity for essential Somali health research by use of the enthusiasm of young researchers and endorsing a Somali-based platform for research communication.8Wall S Emmelin M Krantz I et al.Global health action at 15—revisiting its rationale.Glob Health Action. 2021; 141965863Crossref PubMed Scopus (1) Google Scholar, 9Martin G MacLachlan M Labonté R Larkan F Vallières F Bergin N Globalization and health: developing the journal to advance the field.Global Health. 2016; 12: 6Crossref PubMed Scopus (3) Google Scholar Although we look forward to local health research under Somali leadership and authorship, we also wish to bring the predicament of Somalia and other fragile countries to the attention of the global health community. We would like to forward a plea for international cooperation and support in essential health research in the spirit of equality and solidarity. We declare no competing interests. We thank the conference scientific committee for reviewing the submitted abstracts and the Public Health Agency of Sweden, WHO, and the Alliance for Health Policy and Systems Research for their technical and financial support with the conference.