NATIONAL HEALTH POLICY

1.               Introduction

1. Since independence, Somaliland has committed itself to state building process in a relatively secure and peaceful environment. Since the beginning of the 1990s and thereafter, Somaliland has seen remarkable progress on many fronts: not least a unique reconciliation process, the creation and implementation of functioning governance and judiciary system, and a democratization process that has led to free and fair elections and a multiparty legislative system.

Health Sector Reform is a sustained process of fundamental change in policies and institutional arrangements of the health sector, usually guided by the government. Any meaningful reform process ought to be based on evidence and information about the current state of affairs, and potential effect of alternative policy choices.

1. Rationale for developing the second edition of the National Health Policy – henceforth referred to as called NHP II: The Ministry of Health and Labor in 1999 (Now called Ministry of Health) developed the first national health policy. NHP I steered the country from 1999 until 2011 through the immediate post conflict era and following independence. During this period decentralization processes commenced and some functions of the Central Ministry were appropriated to the regions; new partnerships were formed; a series of operational (technical) policies were also drafted; experiences in the establishment of the core functions of the Ministry were gathered; and other significant milestones such as financing options, legal framework, and implementation arrangement options (EPHS, NHPC, new professional schools, new cadre of health workers) were reached during the period. Discussions also commenced on establishment of a Central Medical Stores (CMS) and a Drug Authority, and partners continue to provide drug kits to the health facilities. A national HMIS system was developed and tested. Vision 2030 and the National Development Plan for 2012-2016 were also developed by the Ministry of National Planning and Development. This period also coincided with regional and international milestones that had national rippling effect. For instance, the Paris Declaration (of 2005), the Accra Agenda for Action (of 2008), Abuja Declaration (of 2001) and others focusing on Aid effectiveness (alignment, harmonization, joint analyses, etc.) took place at these times. Polio campaign strategies and Child health Days were also introduced at international level as they continue to have implications at national level.

Hence, NHP II builds on experiences of NHP I and much more; it serves as the point of departure and framework for investment in national stability and development framework contrary to the past post-conflict transition strategy. It seriously considers decentralization of authority and responsibility within the context of national decentralization framework. NHP II further sets the agenda for Public Private Partnerships and proposes a feasible organizational structure that can implement the Policy. The new policy proposes concrete ideas for good governance (transparent and accountable leadership; restructure of Central level MOH and role clarification; clinical leadership in hospital management; the role of Regional Health Committees), quality health care at community, district and regional levels (through conception and adoption of EPHS implementation framework) and service integration, regulatory mechanisms for drugs, supplies and human resources for health, robust quality human resource management, improvement in drug supply chain, innovative mechanisms for financing health services, viable institutional arrangements, a and client charter.

The NHP II was developed through intense consultative and participatory process. The leadership of the Ministry of Health, Directors and other staff, regional staff, parastatals, relevant Ministries, health development partners and other stakeholders had series of meetings and workshops to review the Situation Analysis conducted, set priorities, develop the vision and mission statements and reviewed what was still useful in the NPH I that could be relevant in NPH II. The success of this NHP II will depend on how far these milestones are implemented and achieved.

BOX 2

The Government of Somaliland is implementing a Health Sector Reform Program which focuses on increased utilization of quality health services especially by people in the underserved area, by improved access to quality and responsive health services, strengthened governance and management in health sector, improved institutional mechanisms for community participation and systems for accountability; and strengthened financial management systems.

2.               SITUATION ANALYSIS

2.1             International Context

• In the last two decades that the world has been focusing on poverty reduction, there have been considerable improvements in childhood and maternal morbidity and mortality in developing countries. In addition, successes have been made in combating extreme poverty, expanding access to clean water, improving prevention of mother-to-child transmission of HIV, expanding access to HIV/AIDS prevention, treatment and care, and controlling malaria, tuberculosis and neglected tropical diseases.

• Quantitative investment in health is a major driver that can facilitate the achievement of the MDG by 2015, especially in resource poor environments. In 2001 in Abuja, Nigeria, heads of States and governments in the African region made a commitment on Health Financing for reaching the MDG by pledging to allocate at least 15% of their domestic national budgets to health. This commitment was re-affirmed at a Special Summit on HIV/AIDS, TB and Malaria in 2006 in Abuja and at the 15th Session of the AU Ordinary Summit in 2010 in Kampala. With very little doubt, partnership between the West and the South will facilitate this process.

2.2             National Context

• Somalia civil war seriously affected the whole country politically, socially and economically. Health care delivery institutions suffered a lot; hospitals, health posts, MCH Centers and other health institutions were either seriously damaged or completely looted. Trained health personnel in massive number migrated overseas. With all this damage Somaliland succeeded to gain a political shape as ―Somaliland‖ during 1991 with a stable government and considerable level of peace. After that Somaliland started a new national life through rehabilitation of health institutions, calling back migrated trained health personnel and working for other development activities.
  • Geo-Political, Economic and Demographic Situation. The Republic of Somaliland is situated north of the equator in the Horn of Africa. The total area of the Republic of Somaliland is 137, 600sqkms, and it has a coastline which is 850kms long. It is semi- arid. The average daily temperatures range from 25oC to 35oC. Somalilanders recognize four seasons in the year. The administrative structure of the state consists of three branches: the judiciary, legislative (the House of Elders and the House of Representatives), and the executive arm. The ministers may not be appointed from Members of Parliament. The country is divided into 6 regions, and these are sub-divided into electoral districts. The population of Somaliland was estimated at 3.85 million in 2009 with an annual population growth rate is 3.14%. Life expectancy at  birth  is between 49 to 60 years. The population consists of nomads (55%) and urban and rural dwellers (45%). The population density in the Republic of Somaliland was estimated at 28 persons per square km in 2009.

The current projected income of Somaliland put at $50 million is optimistically expected to double by next year and then by 2013 to $160 million (the health sector only receives about 3% of this, although it is expected to double in the coming year). The recent lifting of a ban on livestock exportation on the grounds of fear of Rift Valley Fever by Saudi Arabia has gone a long way to improve the outlook of the economy. International companies such as Coca Cola previously based in Mogadishu are beginning to move to Somaliland thus boosting the country‘s economy.

1. Health Status: Somaliland has one of the worst maternal mortality ratios in the world, estimated to be between 1400 and 1000 per 100,000 live births. Life expectancy at birth is between 47 and 57 years. The infant mortality rate is 90/1000 while the under- five mortality is about 145/1000. Fully immunized child is a mere 5%. Environmental sanitation is highly challenged. The top 10 leading causes of morbidity are mainly the preventable and curable infectious diseases.

Maternal mortality is the leading cause of death among women of reproductive age. It is caused mainly by hemorrhage, puerperal sepsis, eclampsia and obstructed labor. Women in Somaliland have a one in 15 risk of dying of maternal-related causes. There are a little over 100 doctors in the country both in public and private sector and about the same number of registered midwives. In the public sector in 2011, there are 15 hospitals, 87 MCH and 165 health posts in the country. All these health indicators reflect the seriousness of the health situation in Somaliland.

1. Determinants of Health: As a result of prevailing poverty and high illiteracy as determinants of health, many of the common diseases are those of poverty (communicable diseases) as well as those associated with post-conflict situations. Poor hygiene, lack of safe water, poor sanitation and disposal systems as well as unsafe housing environment forms the antecedents of common illnesses. Hence, Diarrhea, Dysentery, Typhoid, Acute Respiratory infections, Tuberculosis, Chronic Bronchitis, ear infections, etc. are in the top causes of morbidity. Low utilization of health care is another cause of poor health as well as occupation. There are the pastoralists and the nomads. Access to health care is a major problem for the nomads. Cultural factors also determine the health outcome. FGM and its attendant long term suffering for its victim is a case in point. Diet, living style (smoking, chewing, injuries, etc.), post-traumatic stress disorder and lack of physical exercise equally contribute to growing body of non-communicable diseases. This may be more significant as people begin to adjust to the new urban sedentary life and also as people living in the diaspora return home.

In summary, the determinants of health are as follows:

•          Generalized and persistent Poverty

•          Early age at marriage

• Patriarchal society – limits access to services for women
  • Culture and religion sometimes limit access to allopathic health care; FGM

•          Sexual abuse and sexual violence

• Occupation – nomadic population and lack of access to health care
  • Inequitable access to services: Rural dwelling, Nomadic lifestyle
  • Poor health systems response: Due to shortage of health power, vaccines, drugs
  • Unhealthy lifestyle: Smoking, lack of exercise, use of hard drugs, car accidents,
  • Post Traumatic Stress Disorder: Mental illness

1. Organization and management of the health sector (Governance): The MOH is the public institution responsible for the health care of the nation. It is charged with the overall production, delivery and coordination of the health sector and assuring Somalilanders of good health.

The Ministry of Health is headed by a Minister who is appointed by the President. He is supported by the Vice Minister. Their role is policy formulation, advocacy, external relations and serve as the bridge between the people of Somaliland and the Government. The Ministry is administered by the Director General and has six departments under him namely: Planning, Human Resource Development, Finance and Administration, Health Services, Public Health and Communicable Disease Control. Currently, there is no  Health Act for the national health system

Like a few other government Ministries, MOH has been decentralizing its functions and power to lower levels. The country currently has six regions. A Region is headed by a Regional Medical Officer, who is appointed by the DG of MOH. The structure of the regions mimics that of the Central MOH but mainly focuses on support to the district health program. Each region has a Regional Health Board whose composition represents the community. They are usually seven and have oversight functions on all health institutions in the region including the hospitals, the regional health office, health centers, etc. However, they have been known to fully support fund raising, especially for the hospital. As they are usually from the business community, they are unable to provide clinical oversight required for the hospital‘s clinical work.

Especially at health facility level, there is indiscipline and lack of ethics. Health workers generally work for less than 4 hours before going to their private health facilities..

As contained in Article 17 of the 2001 Constitution, the commitment of the government of Somaliland to sound health and prosperity of its people is unshakable. The MOH is evolving and has come a long way from 1991 when the first post independence government was formed. There is still a dearth of skills for planning, policy development, vision, planning, program formulation, implementation, M&E at all levels. Roles are not clearly defined and these sometimes have led to duplication of efforts, confusion and inefficiency. The organizational structure is still very traditional and unresponsive to existing health management challenges. Although there are no technical guidelines, checklist, or other tools for mentoring regional and health facility staff, however, many technical/operational policies have been drafted and await approval before implementation. Some of these draft policies include: Human Resources, Drug and Reproductive health, etc.

Realizing that medical graduates are not registered, private and public health facilities are not licensed and health training schools are not accredited, a National Health Professional Council (NHPC) has recently been revamped a board of directors formed. The office is not yet fully functional. For instance, it is has no budget of its own and is currently fully supported by an international partner. When fully operational, its role will be to register all medical and allied medical graduates in the country, accredit all health training institutions and license all health facilities (private and public) for medical practice and assurance of compliance with ethics.

Drugs and health supplies are not regulated especially in the private sector but also in the public sector. Importation of drugs by unlicensed traders prevails throughout the country.

In general, there is a general lack of coordination across and within the health sector. Not only is there a lack of coordination of partners working with MOH, there is also a lack of coordination within the MOH structure. The financial system is still weak and would require systems strengthening.

• Health service delivery: Delivery of health care in Somaliland is comprised of the public sector system of Hospitals, Referral Health Centers, Health Centers and Primary Health Units; and the private sector (for profit) system of pharmacies, clinics, laboratories and traditional medicines. In addition, there are the Private not-for profit hospitals and clinics. Some of them are supported by international organizations and others are owned by individual philanthropists.

• The Public Sector delivery system: The public sector health system consists of the EPHS framework which includes the Primary Health Unit (PHU), Health Center (HC), Referral Health Center (RHC) and the Regional hospitals. Furthermore, there are Specialist hospitals (TB, Mental and FGM) as well as the Hargeissa Group Hospital (HGH).

The PHU is the closest facility to the community. It serves a population of about 300 households, approximately 2000 population. It is staffed by at least one trained CHW  and supported by a member of the CHC) and provides basic care for prevention and promotion including maternity services to the community. The CHW is not a nurse but is trained to diagnose common diseases, provide antenatal care and also assist in uncomplicated deliveries.

The HC is the first level that has a qualified nurse, midwife and auxiliary nurse and a community midwife. The HC provides outreach support services to the PHU, covers a population of about 5000 people and serves as a referral point for the 2-3 PHU.

The HCs receive support from International agencies (drugs and equipment for OPD and maternity as well as incentives for health staff) in addition to regular contributions of the MOH.

There are regional hospitals in the six regions. In addition, there are seven TB hospitals and four TB centers. There is also a Fistula hospital in Buroma and Hargeissa and are supported by South Africa and UNFPA. Several of these regional hospitals are supported by international organizations as they renovate, procure drugs as well as provide incentives to health staff, in addition to government‘s own contribution that includes standard setting, refresher training, supportive supervision and remunerations. The Hargeissa Group hospital is inefficient in its management, public property is being used for personal gains and there is weak clinical supervision, among others. All these have resulted in loss of public confidence in the hospital.

Like in many resource-constraint regions of the world, referral care in Somaliland is a major challenge. The referral system between various types of health facilities is either non-functional or ineffective. EmOC is missing in practice. Distances are very far apart making referral a major challenge and there is no transportation. There is a current inability of the system to cater for emergency transport needs of the nomads to hospital. Furthermore, as a result of traditional or cultural barriers, clients usually report as emergency in late stages of disease. However, some hospitals with support of international donors and partners have ambulances and effective communication system for cases of emergency. They are testing out several initiatives worthy of note:

• Referral care logistics through use of Coupons for transport and other innovations
  • Risk assessments which can reduce emergency referrals

Health services utilization is still limited in Somaliland due to uneven distribution of health facilities especially in rural areas, inadequate supply of drugs resulting in shortages of drugs and other health supplies and the shortage and low motivation of human resource in the public sector. For instance, it is known from surveys that less than 15% of the rural population is able to use the public system for regular complaints as there are major barriers to access and utilization in rural and urban areas.. The functionality of the health system in Somaliland is a challenge and systems strengthening especially at district and community level will be required to effectively deliver services.

The strengths of the health services can be summarized as follows:

• Basic infrastructure and equipment available and in relatively good condition
• Donor support strong in hospitals
• Chronic shortages of drugs not common
• User fees are being used at the point of collection (mainly in the hospitals) for improvements

The weaknesses of the health services can be summarized as follows:

• Health infrastructure is not enough to cover the entire population and respond to their needs. There are less than 300 although the country will require over 1700 units.
• Very poor health indices
• Routine immunization coverage rate is low
• Patient management is poor
• Delivery still takes place at home and by TBAs.
• Preventable diseases account for major causes
• Programs are still very vertical
• No clinical supervision & community outreach
• Consumer knowledge weak
• Health facilities not accredited

• Private Sector: Over 60% of the health market is dominated by the private sector. The private system comprises of the private not for profit organizations (PNFPs), private health practitioners (PHPs) and the traditional and complementary medicine practitioners (TCMPs). The PNFPs are larger, better organized and with greater structures than the other sub‐sectors. They also have better collaboration with MoH. Even though the private sector provides a significant proportion of health services, it is not properly integrated with the public sector to fully take advantage of each other. The non‐facility based PNFPs have not been properly harnessed to support health promotion at community level. Improving the partnership at regional level will enhance capacity to provide health promotion and disease prevention, among other services.

The Private not‐for‐profit subsector (PNFP)

Private Health Practitioners (PHPs)

PHPs provide mainly primary care services and have a large urban presence. Although existing relevant legislation provides for licensing and regulation of health professionals who engage in private practice, the expansion of private health providers has largely been unregulated and chaotic. The large pharmaceutical (importer) sub‐sector is however better regulated. Recently, the Wholesalers have been organized by the MOH for quality control of importation of drugs into Somaliland. The number of pharmacists and pharmacy technicians is low and most people doing pharmacy work are not qualified. There is also a Pharmacy Committee recently established and have done a great job of control of drug purchase such that they only purchase government-backed drugs from Wholesalers.

Traditional and Complimentary Medicine Practitioners (TCMPs)

Approximately 60% of Somaliland-ers seek care from TCMPs (e.g. herbalists, spiritualists, traditional birth attendants and traditional dentists) before visiting the formal health sector. Many traditional healers remain unaffiliated. In the communities, most TCMPs have no functional relationship with public and private health providers.

1. The Performance of the Health Sector.

• Child and Reproductive Health: Clinic attendance at Primary level in the public sector is rather low, even though the private sector is flourishing especially in the cities. More deliveries take place at home (31.1%) than at the health facilities (9%). Antenatal clinic attendance (at least four times through pregnancy) is very deflating at 4% and (at least once) 26% respectively. Antenatal care by qualified staff is also less than adequate; a significant percentage of women are multiparous and use of family planning methods is extremely low. Positive response to ever use of any method of contraception is only 22%. Most of these use the ineffective coitus interruptus or breast feeding according to Islamic law. Very young women who are prime-gravid also pose imminent danger to the attending clinician. With over 80% of women and girls under-going it, the Type III Female Genital Mutilation (FGM) is most commonly practiced in Somaliland. It is also the most harmful as the procedures leave a lifetime of physical suffering for the women. There is a National Network for FGM in Somaliland and the Network has just established the Magan Maternity hospital. Post traumatic surgeries are conducted monthly in addition to counseling. The National Fistula hospital in Boroma has over 30 cases per month for treatment of medical complications.

Routine fully immunized coverage rate for children 12-23 months is still very low at about 5% and measles immunization coverage is 19%. In some regions, DPT drop-out rate is as high as 75%. All these contribute to high VPD. Malnutrition, especially chronic malnutrition, is also a prevailing disease resulting from persistent food deprivation, while exclusive breastfeeding is only 13%. Effective treatment of pneumonia is 33% while effective treatment for diarrhea is a mere 7%.

Service utilization is low, mainly as a result of the poor quality of the service, the lack of health-care facilities, and customer preference for private service providers. Some people live as much as 100 km from the nearest health facilities. Sometimes, these facilities are also poorly equipped in human and material terms and do not have much to offer for the critically ill. Particularly for the nomadic population, access to health care for such emergencies as difficult labor and childhood illness is very poor and could make a difference between life and death.

• Malaria Although malaria cases appear to be dwindling in some parts of the country, the disease still remains a public health challenge in Somaliland. Both ITN and IRS are being used as preventive approaches in different settings of the country. A combination therapy (Fansidar and Amodiaquine) is also approved for case management. IPTp has been removed from the Malaria policy.

The major challenge for malaria in Somaliland is to effectively balance implementation of strategies for control and sustained control as there is high transmission as well as seasonal transmission in this resource-constraint country. Until local field research suggests that coverage can gradually be targeted to high risk areas and seasons only without risk of a generalized resurgence (Sustained Control), the national program remains in the control phase of the Global strategy.

• HIV and AIDS: HIV sero-prevalence surveys in Somaliland have consistently shown that HIV is an emerging public health problem as the median prevalence is considerably higher than in other countries in the MENA region. HIV prevalence is also higher among TB and STD patients and indicates that the prevalence may also be higher among other high risk populations. Therefore, this calls for an urgent initiation and implementation of TB/HIV collaborative activities in the country.

• Tuberculosis: The disease is significant and is on the increase in the country as under-nutrition is a significant and enduring public health problem here. Rates of acute and chronic malnutrition have remained persistently high throughout Somaliland with some variation by region and livelihood system. DOTS approach is the current strategy being implemented for case management. Poor hygiene practices, inadequate housing, poor health seeking behaviors and low access to quality health services are some of the factors that propagate TB in the community. Although the social determinants of TB are grounded in the community, the emphasis is still case management at clinic level. There are seven TB hospitals and three Centers throughout the country.

• Mental Health. Mental illness is a significant challenge to Somaliland. The cause includes depression from the civil war, drug/substance abuse, in addition to anxiety, depression, schizophrenia and organic psychoses.

GAVO, a CSO, has been engaged in advocacy to government and international community and creating internal and community awareness on the situation of mental illness in the country. THET has also been involved in incorporating mental health into training curriculum of a wide variety of health practitioners.

Again, there is an emphasis on hospital admission and treatment without looking at the community that generates these patients due to unhealthy life-style. Community awareness and education will be required if Somaliland would make a concerted effort in reducing this burden of disease.

• School and Adolescent Health: Not much is being done in the area of school health (oral health, health education, immunization, alcohol and drug reduction program, HIV/AIDS and STD, Communication for Behavior Change, etc.). Many of these lifestyle related illnesses are becoming more common among school, adolescent and youth.

• Environmental health and Sanitation: This is another major challenge of Somaliland. It is the leading cause of many diseases in the country.

• Non-Communicable Diseases: Non Communicable Diseases are on the increase. The cause is related to diet, living style (smoking, chewing qat, injuries), post-traumatic stress disorder and lack of physical exercise. This may be more significant as people begin to adjust to the new urban sedentary life and also as people living in the diaspora return home. However, nothing is currently being done about it in terms of awareness creation and education, prevention and promotive care.

1. Monitoring and Supervision: The Regional team and the District Health Teams (where they exist) supervise service delivery at government health facilities at the Primary care level. However, challenges exist: supervision and monitoring visits are irregular and poorly documented; there is a lack of tools and human resource to conduct supervision especially in newly created districts; lack of supervisory skills at district and regional levels; lack of transport for supervisory and monitoring visits; and inadequate budgets. Efforts at national level to organize and support clinical supervision of the Regional hospitals have not been very successful. In general, technical supervision is weak and this has affected the quality of service.

The national HMIS unit has developed a HMIS for the country and has been rolled out to the regions. This comprises national guidelines for reporting deadlines and channels, as well as revised and standardized data collection tools. The monthly forms have been implemented in all MCHs and hospitals at regional level. The Health Post level tools are currently under development.

Current challenges faced include:

• The national priority health indicators have not been reviewed
• Different data collection systems proliferated by vertical programs and supporting agencies
• Poor quality of data generated at SDP level mostly contributed by low skill level, low staff morale and lack of data use at collection level
• Available data from MOH not used at any level for decision making
• Lack of proper integration with other systems of data collection in place e.g. Disease Surveillance system
• Lack of other critical sources of complementary information such as: Population & census data at regional and lower levels; Periodic Demographic and Health Survey (DHS) data; Research data

• Private sector not providing periodic service statistics
• Lack of precise demarcations for catchment areas of facilities

1. Human Resource for Health. Somaliland is in short supply of qualified health professionals as a result of the war and exodus of trained personnel abroad. Currently there are two medical schools, five Nursing Schools and two Schools of Midwifery. These schools are not well coordinated. The curricula used are not well known and approved by the MOH. The total enrollment is still low for the demand in the country and the production is not regulated. Except for the medical colleges, these training schools have not been accredited. The graduates are not registered in accordance with Law No  19 of 2001.

There is no standardized system in place for CPD and criteria are not available to be followed. Distribution of health workers in the country is also skewed in favor of the cities and big towns. Health workers generally work very short hours and attribute this to low wages. Performance assessment is either weak or lacking as there are no clear guidelines for hiring and promotion, or any performance appraisal system, sometimes leading to preferential treatment. However, MOH recently published an Operational Policy and Strategic document which details governance, planning, production of health professionals and continued education. Salaries are extremely low and this has led to employees spending less time at work and looking for additional income in the private sector. A human resource consultant is currently assisting government to develop job description for the leadership including all the directors.

In summary, the strengths of the Human Resource department are as follows:

• A Human Resource policy available
  • Relatively good work environment for staff by INGOs working there
  • Increasing number of Health Training schools and health graduates
  • Some HRM tools have been developed
  • HR management database has been established
  • Standardized RN/RM, MD, NTT curricula are now available
  • Head count assessment of all MOH completed
  • ID for all health personnel partially also completed

The weaknesses are as follows:

The opportunities availed are as follows:

• Training schools are supported by government and stakeholders
  • There are 2 Medical schools; 5 SON, 2 SOM
  • Availability of trained Diaspora and willing to come back
  • Internship and national service program in existence

1. Drugs, food and Pharmaceutical safety and Supplies In the public sector drugs  are provided by donors and partners. These drug kits for PHC arrive in country and are stored in the Central Medical Stores in advance for distribution to health facilities. There are frequent shortages because drugs are distributed quarterly and are never enough to cover the three months. The kits are prepared outside the country and sometime do not reflect what is in the essential drug list of Somaliland. Especially in the private sector, there are still problems with drug safety, counterfeited drugs and proper storage. There are problems with irrational use of drugs.

The weaknesses are the following:

• There are no systems for drug registration
  • There is no quantification done
  • There is no procurement procedure in place
  • Irrational drug use rampant
  • Public has unlimited access to all types of drug
  • Licensure mechanisms for all private health outlets not in place
  • Same drug kits given to all PHC (PHU or MCH)

The prevalence of diarrhea, dysentery and typhoid fever are an indication of microbial food poisoning and lack of food safety. Food premises are not licensed and food handlers are not certified by the MOH.

In general, the opportunities availed to Somaliland in the area of drug control are the following:

• A Pharmaceutical Steering Committee is being negotiated. There will also be a Wholesalers Union. This group will assist with Quality Control for imported drugs

• The Drug Kit and other drug donation will serve to build lasting national system
  • An Investment Plan of Action has been submitted to a donor for possible funding as seed money for initial procurement for the DRF drug.

As a result of all of the above, a major funding gap for program development and scaling- up of priority public health interventions exists in the sector. At the same time the increase in personnel emoluments have not risen to the point where the salaries in the sector are comparable with those in similar settings in other countries. Hence, a good size of resources from partners are used for salary top ups as well.

Collection of user fees has been dwindling in recent times, especially where partners are supporting hospitals. Where user fees are collected, they are generally used at the point of collection for infrastructural improvement, including payment of volunteer workers such as CHW. Active implementation of exemption strategies is yet to take place.

In general, Concept of co-management and co-financing relatively are well developed and functional for Hospitals; Contributions from the Diaspora is uniquely innovative; RHB able to raise funds locally and also from the Diaspora for programs; and Some community members and the Elders make substantial in-kind contributions to the health sector.

However, there is no health financing policy; Government allocation very low at 3%; Public expenditure on health is less than $5 per capita, compared to the recommended $40 by WHO; Councils are unable to contribute because the taxes are centralized; Strategy for efficient revenue collection from private health facility not been fully developed; and MOH has not taken advantage of the full range of financing options. The opportunity here is that EPHS provides a good opportunity to experiment with  innovative approaches to financing the health system through various models for cost sharing and cost recovery

1. Partnership for Health: Partnerships between and among government Ministries, donors, charity organizations, private for-profit, development partners, NGOs and the community remain critical to the achievement of health and development goals of the country.

At the international level in Nairobi, new donor partners are expressing interests in supporting Somaliland. However, all donor meetings continue to be held in Nairobi and not in Hargeissa. At the MOH level, a quarterly National health and nutrition coordination meeting is in existence and brings donors, partners and government to dialogue on planned and completed activities. Similar meetings take place at the regional level as well. Some technical Working Groups have also been started and are on-going.

1. Research: Research agenda for health service, epidemiological and biomedical research are not currently available. Universities are probably involved in some forms of epidemiological research but are not coordinated and government is not fully aware of these events. There are no priority research agenda and capabilities are not determined. Even so, data is not available for planning.

1. Opportunities: There is a new government that has promised to provide good governance with astute values. A new law has been passed that defers the responsibility of the PHC system to the Councils. This could encourage the participation of the Councils in primary health care. Furthermore, an NGO Law is now in place and ratified by Parliament. The AID instruments such as the Vision 2030, National Development Plan 2012-2016 and the National Aid Coordination Policy are all opportunities provided by government outside the MOH to ―speak up‖ to the donors.

With regards to the health services, EPHS framework provides opportunity to take control of the health service delivery systems; there are also opportunity for service delivery options through results from existing projects of local and INGOs; and finally, nomadic orientation challenges the current health system mode to be creative.

NHP II has been largely informed by the National Development Plan 2012-2016 (NDP) which serves as a guide for development resource allocations for the Somaliland Government and its development partners in a strategically consistent manner. The main response strategies to the NDP on the part of Somaliland‘s development partners—the United Nations Transition Plan (UNTP); the Joint Strategy Paper of EC, EU countries, and Norway (JSP); and the World Bank‘s Interim Strategy Note (ISN)–were the first attempts to align international donor support to national priorities. The NDP explains  how economic development exemplified by, for example, reduction in prevalence of poverty can be achieved. Economic development is dependent on social and human development. Improvement of people‘s health is both an outcome and a cause of economic development. The NDP prioritizes the implementation of the EHPS. The NHP II has also been formulated within the context of the provisions of article 17 of the Constitution of the Republic of Somaliland (2001) which decentralized governance and service delivery. Following this, the MoH has delegated responsibilities to the regions for them to manage the delivery of health care.

1.2               The Vision and Mission Statement

Vision: For all the citizens of Somaliland to attain the highest quality health status and social wellbeing equitably and sustainably.

Mission: To create an enabling environment for the provision of socially acceptable, affordable, accessible, equitably distributed essential package of quality health care that responds to the need of the community, with special attention to the most vulnerable in the population and delivered in a sustainable way through a decentralized health system within Somaliland.

This mission may not be met without the following assumptions: public private partnership; resource mobilization from the community; community participation in the management and financing of health services; and the reduction in the dependency of the health system on external finance through an increase in the Government contribution to the health sector.

1.3               Policy Objectives

The following policy objectives have been set up in order to achieve the mission of the Ministry of Health:

1. The objectives of the health policy will be achieved by emphasizing the following core values and Guiding Principles:

Core values:

This policy puts the patient and community in the forefront and adopts a ‗client‐centered‘ approach and it looks at both the supply and demand side of health care. The following social values, as detailed in the Constitution of the Republic of Somaliland and the Patients‘ Charter, will guide the implementation of this policy: Integrity; ethics; equity; gender-sensitivity and accountability.

Guiding Principles:

The National Health Policy shall be guided by the following principles:

• The    implementation     of    the    NHP    II    shall     be    ‗evidence‐based‘    and forward‐looking‘, as has been the development of this policy.

• The NHP II shall be based on sustainability. To ensure that the inputs of today can be sustained over a longer term, beyond the life of donor funds
  • Integrated quality care that is socially acceptable, affordable and accessible, and supporting continuum of care.
  • Efficient utilization of health care at all levels.
• NHP II shall be pro‐poor oriented and shall provide a policy framework that shall support SERVICE FIRST within sustainable development approaches.
• PARTNERSHIPS with other government ministries, institutions and the private sector.
• PHC shall remain the major strategy for the delivery of health services in Somaliland. PHC, based on the district health system, explicitly recognizes the role of hospitals as an essential part in a national health system.

4: National Priority Interventions

The situation analysis identified a number of challenges that need to be urgently addressed through policy guidance. Poor governance has retarded the progress of work at the MOH and has not made it to achieve its maximum potential. This has also tricked down to the health facilities including the hospitals. Technical leadership is also lacking in the MOH. Technical guidelines and protocols are either not developed or are not followed at the health facilities. Regular supervision is not conducted either by the Regions or the Central MOH. Furthermore, there is a dearth of human resource for health as well as financing for health and drug control.

The focus of the policy shall be universal provision and utilization of the EPHS to all people in Somaliland with emphasis on vulnerable populations. The selected interventions shall not only to be cost‐effective, but also affordable. For many of these diseases, cost‐effective and affordable primary, secondary and tertiary prevention interventions and services are available. . They shall therefore constitute the core health interventions in this health policy.

In summary, the top priorities for the MOH in order to achieve the policy objectives are:

• Improve Governance functions at Central and Regional levels, as well as promote best practices in hospital management and clinical leadership
• Improve the expansion and quality of EPHS in order to improve quality of services provided at the health facility level (including referral care and client charter) and expand service delivery options. Promote awareness and contribution to improved personal health care through prevention and health promotion.
• Improve behavior/Social change (including Prevention and Promotion in households
• Establish a concrete Human Resources for Health approaches
• Develop sustainable Health Financing options
• Control Drugs and Consumables and enhance its supply to health facilities
• Improve physical access to quality health services in private and public facilities
• Monitoring and Evaluation

Government shall adopt a decentralized planning and management system in close collaboration with the community. Managerial and administrative capacity will be developed at all levels within the context of decentralization. Government shall design mechanisms to supervise, monitor and evaluate the implementation of the Health Sector Policy with a focus on specified input and process indicators: evaluation will be conducted both internally and externally in collaboration with the Ministry of Health‘s partners. Finally, the Health Management Information System (HMIS) will be reinforced to better inform decision-making in the health sector.

4.1             Governance

Partnership with the donors shall continue to be strengthened. MOH shall strive to host in Hargeissa Donor meetings hitherto held in Nairobi. The health sector shall continue with the decentralization process that has started and strengthen the Regions and gradually initiate a District Health System (DHS) to manage and deliver quality health services. A lean and efficient organizational structure that is based on core functions of the central MOH will evolve to support and implement the NHP II and prioritize management and technical oversight of the regions (See Appendix 1). Above all, government will not tolerate any act of indiscipline and/or lack of ethics in the health sector. Financial Management system shall continue to be strengthened.

The aim of good governance in the health sector is to create an enabling environment that is participatory, consensus oriented, accountable, transparent, responsive, effective and efficient, equitable and inclusive and follows the rule of law. It assures that corruption is minimized, the views of minorities are taken into account and that the voices of the most vulnerable in society are heard in decision-making. It is also responsive to the present and future needs of society.

The following are the main objectives of this section on governance in this policy:

1. Review and implement the structure of Central and Regional MOH levels to ensure efficient and effective management of the health sector
   1. Emphasize Service integration over verticalization of programs;
   1. Inspire confidence in the donor community and stakeholders through demonstration of transparency, accountability, improved Financial Management Systems and effective use of resources; and hence generate additional resources for the sector.
   1. Re-emphasize its regulatory role through establishment of government parastatal organizations such as NHPC and the National Drug Authority and delegate its Regulatory functions (licensing, registration and accreditation) to these institutions.
   1. Phase out the total control of the management of the hospitals and hand over to a CSO/NGO to manage them along with an independent multi-sectoral hospital management board.
   1. Improve coordination with partners, donors and other stakeholders

4.1.2         Policy Strategy:

Government shall

• Strengthen the Central MOH to carry out its core functions including Policy formulation; Strategic         planning;   Resource    Mobilization;                       Monitoring    and

evaluation; External relations (Donor coordination); Legislation and Inter-sectoral collaboration.

• Implement a gradual decentralization of power and authority to the regions and districts to implement the national health policy and strategies;

• Initiate and support development of the District health system which will be in line with the administrative/political district system.
• Support the creation of various community committees at different levels: as village, community, PHU and HC levels. Their roles are to:
  • create awareness in the village about available health services and their health entitlements;
  • develop a Village Health Plan based on an assessment of the situation and priorities of the community;
  • maintain a village health register and health information board and calendar;
  • analyze key issues and problems pertaining to village level health and nutrition activities and provide feedback to relevant functionaries and officials; and
  • To present an annual health report from the village to the health authorities

• Develop strategic integration through team work across departments, divisions, units and programs in order to reduce verticality, fragmentation, duplication and redundancy and increase efficiency and effectiveness.
• Develop a costed strategic and operational plan for investment in the health sector; and avoid stand-alone, vertical program and projects.
• Develop a new Financial Monitoring system that will be effective and efficient
• Put in place an audit system at all levels to ensure transparency and effective management system. To this end, government will muscle all its strength to fight conflict of interest among service providers and ensure zero tolerance to corruption. MOH shall create an Office of Internal Auditor who will audit the entire management system and report to the Office of the Minister.
• Produce a certified audited annual report
• Establish National parastatal institutions – NHPC, and Drug Authority and have the following roles:

• NHPC: Standard setting, and Quality Assurance; Licensing of all private and public health facilities; accreditation of health training schools and registration of all qualified medical and allied health professionals in the country and enforce compliance. Disciplinary actions will be taken against

• Food and Drug Authority: Quality control of imported drugs; registration of new drugs; inspection of premises, licensing  for importation of drugs; and regularly conduct pharmaco-vigilance compliance

• Eliminate MOH total control of the management of Hargeissa Group hospital (the National Referral Hospital) by:

The MOH will hand over the authority and power to the CSO/NGO and the board.

If this experience proofs efficient, the regional hospitals will undergo similar management reconstruction.

• Begin to organize and host donors‘ meeting in Hargeissa.

4.2             Health Care Service Delivery

As a result of poor health outcomes nation-wide, Government has now adopted a new service delivery framework for delivery of quality health care to the people of Somaliland and has the potential to accelerate achievement of the MDG. The EPHS framework is the essential health care package that is being implemented in Somaliland and it consists of 6 core programs namely:

(a) Maternal, Neonatal and Reproductive health; (b) Child Health; (c) Control of Communicable Diseases and surveillance including Watsan; (d) First aid and care of clinically ill and injured; (e) Treatment of common illness; (f) HIV, STIs and TB

There are four additional programs namely:

(g) Management of chronic disease and other diseases, care of the elderly and palliative care; (h).Mental health and mental disability; (i). Dental health,; and (j). Eye health

The vision for NHP II is to ensure that all Somalilanders have access to essential package of quality health services anywhere they live in the country. This package will consist of an integrated and cost-effective interventions that address promotive, preventive, curative and rehabilitative services for all priority diseases and conditions, to all people in Somaliland, with emphasis on vulnerable populations.

4.2.1         Policy objective

4.2.2   Policy strategies

In order to achieve this policy objective, Government shall:

• Gradually expand health facilities according to arising needs.
• Promote routine health facility outreach programs and population-based, high impact interventions for the population
• Create demand for the community to utilize available health services.
• Advocate for, design and lead the development of the EPHS framework and encourage its uptake by the regions;
• Include all core primary health care services in all the PHUs and ensure availability of recommended health providers;
• Ensure availability of equipment, drugs, laboratory supplies and competent health care workers appropriate for the levels of care
• Initiate a Community-Health facility initiative such that the hard to reach will have a connectivity of basic health and nutrition services with the nearest health facility.
• Use population based campaigns
• Use the Child-to-child; Role model mothers; and other types of appropriate models to provide information to care givers.
• Train co-villagers as advocates for, design and pilot the implementation of appropriate service delivery models for specific population groups such as the nomadic population
• Ensure that at all times adjustments concerning the package necessitated by limitations in the resource envelope for service delivery will be based on the best possible combinations of available options for equity, efficiency and quality of services.
• Prioritize interventions against diseases internationally targeted for elimination or Eradication, such as measles, polio, etc.

• Use Communication for Development including the use of social marketing techniques, to target vulnerable populations regarding the prevention and control of major health problems in Somaliland.
• Gradually strengthen self‐care, especially at primary care level, for selected health problems and patient categories, possibly through –carefully planned and evaluated‐ pilot phases.

Child and Reproductive Health. Government will continue to invest resources in key priority areas such as treatment, counseling and care for safe motherhood initiatives, neonatal, infant and child services; care of the adolescence in reproductive health; family planning; sexual abuse; prevention of female genital mutilation; STDs including HIV/AIDS; and female empowerment. Government will ensure health facility delivery with qualified midwives and birth registration of all births.

Government will continue to facilitate the introduction and expansion of Integrated Management of Childhood Illness (IMCI) strategy in all PHC facilities across the country with improved quality care and referral system for childhood illnesses including Acute respiratory illnesses, measles, malaria, diarrhea and underlying malnutrition. Furthermore, government will ensure an uninterrupted, effective and efficient EPI system whereby all children under two years are fully immunized against all childhood illnesses. Government will support continuum of care.

Nutrition. In order to eliminate childhood and maternal malnutrition and reduce micronutrient deficiencies, government will:

• promote Infant and Young Children Feeding (IYCF) as well as food security across sectors

• All these will be done in an integrated fashion with all PHC activities.

Malaria

The national response to Malaria is to ensure that the Malaria technical policy is implemented. This policy supports preventive actions through distribution of LLIN and use of IRS in regions and communities; use of combination therapy in case management for confirmed (use of microscopy or RDT) cases only; and focalized response to out- breaks through prompt surveillance.

HIV/AIDS

The National response to the HIV/AIDS epidemic consists of developing strategies to prevent, control and mitigate the impact of the epidemic. The Health Sector will continue to lead the national response on technical issues related to the following:

• Prevention and control of HIV transmission strategies, which include: Sexually Transmitted Infections (STIs) services; Blood safety; Prevention of Mother to Child HIV Transmission; Design, development and distribution of IEC print and electronic messages and materials; Health education and promotion; Voluntary Counseling and Testing (VCT); Care of HIV/AIDS patients at both facility level and community home based care; Provision of treatment for Opportunistic Infections and eventually Anti- Retroviral Therapy;

• Impact mitigation and support to affected and infected individuals and addressing the stigma.
• Management and coordination of the health related technical aspects of the national response.
• Supporting and guiding biomedical and health related research on HIV/AIDS.

Female Genital Mutilation: Government shall

Advocate for sustained commitment of government at all levels to the successful implementation of the policy, as well as to legislation and enforcement; Public enlightenment through an Information, Education and Communication network;

Capacity Building through training of trainers, including peer educators and health workers, as well as ensuring the availability of suitable training packages/information manuals/kits on the dangers and consequences of female genital mutilation; Promote research to generate current information, and to monitor and evaluate intervention programs to determine attitudinal changes; Promote alternative skills acquisition, credit mobilization, and income generation for practitioners of female genital mutilation.

Tuberculosis: Government shall:

Epidemic Preparedness. Government will build on the existing surveillance system for effective detection of notifiable diseases. Disease monitoring will be strengthened.

School and Adolescent Health:

Because of their population size and vulnerability/influence on health through modern day communication systems, government shall specially focus on the health needs of adolescence and school children and:

• Promote the acquisition of appropriate knowledge on health by adolescents.
• Train and sensitize adolescents and other relevant groups in the skills needed to promote effective healthcare and healthy behaviours in adolescents.
• Facilitate the provision of effective and accessible information guidance and services for the promotion of health, the prevention of problems and the treatment and rehabilitation of adolescents in need.

(v) Facilitate the acquisition of new knowledge concerning interactions between adolescents and those who may provide them with health care or influence their behavior regarding biomedical and psycho-social issues related to the physical, mental and sexual development of adolescents.

In order to achieve the above, government will support the following strategic thrusts:

• Conduct needs assessment surveys, advocacy, basic and operational research, coordination of partnerships between specialized institutions concerned with adolescent issues.
• Provide comprehensive services, including healthcare, health education and partner with other government Ministries to support personal and job skills training, vocational guidance and training, sport and recreational facilities, and social and legal support to settings in which adolescents are favorably disposed, with emphasis on promotion of healthy lifestyles and use of positive role models to discredit harmful habits.

• Coordinate school health programs implementation and also to ensure the inclusion in school curricula in the teaching of sexual and reproductive health issues, emphasizing responsible sexual behavior and a positive attitude to sexuality as a means of preventing unwanted pregnancies, drug abuse or avoiding sexually transmitted diseases.
• Provide services in special clinics for adolescents within existing facilities, outreach facilities in schools and other places to which adolescents are attracted.

Traditional and Complementary Medicine

The role of traditional and alternative health care to Somaliland people is significant. It is estimated that about 60 per cent of the population use traditional and alternative care system for their day-to-day health care. Traditional and alternative healing services and conventional health services are complementary to each other.

Government will continue to recognize the role and contributions of traditional and complementary health care in shaping the health status of the people of Somaliland; the Ministry of Health will ensure that: the Traditional and complementary health practitioners will be accountable for their own prescriptions, remedies and therapies; the Village Community government will appraise, assess and recommend in a particular locality traditional practitioners for registration by an approved authority; government will continue to pursue legislation to provide for regulation of practitioners, therapies and remedies and other related treatments.

Environmental Health and Sanitation

Environmental health and sanitation, is an important area for promotive and preventive health. It is one of the best indicators for measuring social and economic developments which can be achieved by, among other things) enhanced environmental cleanliness, monitoring of water quality and safety, monitoring of food quality and safety of locally produced foods and imported foods at ports of entry, manufacturing, packaging and sales outlets.

Government will achieve these aims through:

• Delivery of health education and promotion at all levels to individuals, families and communities;

• Formulation of guidelines on different aspects of environmental health and sanitation will be given priority.
• Collaboration with other stakeholders and provide guidelines for achieving better environmental health and sanitation.
• Enforce solid and liquid waste management at each health facility.

National Food Hygiene and Safety

Objective

• The objective is to prevent illness and diseases attributed to the sale and consumption of unwholesome foods by giving consideration to the intricate network of safe production, distribution and marketing of foods.

Strategic Thrusts

• Advocacy through the mobilization of policy makers and key officials in government and the private sector, opinion leaders and NGOs, including the print and electronic media, to the policy objective.
• Enactment of current food hygiene and safety legislation, followed by effective surveillance of food, water, food premises, food handlers, etc.
• License accredit food premises and license food handlers
• Multi-sectoral collaboration of all relevant government ministries and agencies, NGOs and the private sector in the planning and implementation of programs.
• Undertaking relevant research in current food hygiene and safety technologies and their application.
• Adoption and implementation of the Hazard Analysis Critical Control Point (HACCP) system in monitoring and evaluating the different aspects of food hygiene and safety from production through processing, storage, transportation, distribution, marketing and preparation for consumption.

Non-Communicable Diseases are on the rise, especially among returnees from the Diaspora. Government will take appropriate measures for prevention, control and surveillance of NCDs including health education and promotional measures to alert the community on prevention, diagnosis and management of such diseases; case detection through mass community services, etc.

These diseases are commonly cancer, diabetes, lung problems, cardio-vascular problems and those associated with tobacco consumption and other toxic abuses, an inactive life style and environmental pollution. Oral health, the prevention of blindness and physical rehabilitation services for the handicapped people will be improved.

Occupational Health Services

Government shall ensure workers‘ protection against all occupational hazards, which  may occur in their work places such as industries, estates, plantations and other high-risk institutions. Government shall ensure that companies employing over 5 people shall offer health information and services to their employees according to guidelines given by the Ministry of Health.

Chemicals Management and Control

The priority areas for government intervention shall include:

• Raising public awareness on safe chemicals use and handling;
  • Establishing legislation and regulatory instruments to manage chemicals;
  • Establishing enforcement structure for the existing legislation and regulations;

Provision of adequate national capacity to ensure safety through management and control of chemicals and their products;

• Providing guidelines on proper disposal practices of waste/expired chemicals;
  • Establishing a national information system for chemicals management and establishing a National register for chemicals.

Medicines and Health Supplies

The shortage of medicine in health facilities constitutes a major problem in improving health care for the people of Somaliland. Currently the drug kits are donated by international partners and the role of government is rather restricted. Hence, drugs are pushed to health facilities as there is no quantification done. Although drugs are bound to be sent to facilities quarterly, there are usually delays and inadequate financing and lack of trained pharmacists/ technicians contribute to this delay. In the course of this NHP II it is the vision of Government to purchase safe, efficacious drugs on international market, locally assemble the drug kits, quantify the health facility consumption, distribute drugs timely to health facilities and ensure timely availability of the medicines and health supplies to health facilities.

There is general widespread use of Sub-standard and expired drugs, propagated by unlicensed and un-professional traders who engage in marketing drugs and pharmaceutical supplies. They sell all sorts of drugs over the counter and that on its own breeds irrational prescription and use and drugs. There is very little awareness on the dangers of consuming drugs. In general, the regulatory environment is at its infancy.

There is a lack of community awareness of their rights to potent, effective and quality drugs as well as lack of consistent implementation of drug policy and procedures

Policy objective

1. Purchase and safely store efficacious drugs and health supplies
2. Quantify drug and supply needs at health facilities, giving allowance for emergencies needs
3. Assemble and distribute drugs and health supplies to health facilities d). Gradually initiate a Drug Revolving Fund

Policy strategies

In order to achieve this objective, Government shall:

(a) Set up a Central Medical Stores as a Public-Private Partnership company where government, private sector including civil society will have shares.

• Purchases will be limited to manufacturers with WHO certification.
• Ensure adequate financing of essential medicines and health supplies in the national budget and gradually reduce donor dependency over time
• Explore opportunities for local production
• Train pharmacy staff in how to conduct a quantification assessment
• Ensure proper management of drugs including stock levels that will inform quantification needs from the lower level health facilities to the national level.
• regularly update the EDL such that the assembly of the drug kits is appropriate to the level of delivery of healthcare
• provide additional funds to cover transport and other contingency needs, in addition to the drug investment funds
• Train staff in the principles/procedure of DRF
• Ensure that money generated from the sale of drugs are re-invested in the purchase of drugs and consumables.
• instruct health facilities to strictly follow the DRF rules, regulation and procedures including the opening of a separate ―pharmacy‖ bank account

(l).Take into consideration EXEMPTIONS for those who are unable to pay; and cover emergencies through a separate grant

(m) Promote, support and sustain interventions that ensure rational prescribing, dispensing, better diagnosis and patient compliance in the use of medicines and other supplies;

(n). Create awareness on irrational use of drugs (o). Train the community on the curriculum

(p). Conduct baseline to generate data on personnel involved in irrational use of drugs (q). Continuously promote best practices

4.3             Development and Management Human Resources for Health

The health sector recognizes the critical role of human resource in health in terms of both quality and numbers in the delivery of the quality of health services to the population. There is however, unregulated health training institutions in the private sector, a shortage and mal-distribution of human resource, many staff are poorly trained, poorly motivated, and leadership and management skills are inadequate at management level. There is inappropriate mix of skills and categories for Human Resource for Health. Performance assessment is weak and salaries are extremely low.

The vision of Health Resource management in health is to avail the health facilities with well trained, skilled, motivated and sufficient workforce equitably distributed across the country.

Policy Objectives

1. Increase and maintain rationale production of required quality HRH
2. Appoint and equitably distribute qualified staff to positions throughout the country
3. Ensure retention of staff through compensation commensurate with their skills level and career development
4. Re-introduce Continuous professional training for HRH e).Promote a culture of merit-based performance at work f). Reinstate discipline and ethics among health workers
5. introduce Professional registration, licensing and accreditation

Policy Strategies

Therefore, Government shall:

• Invest resources in the training of all health professionals.
  • Regulate and strengthen training institutions, including the training curricula and trainers in close collaboration with Ministry of Education (Higher Education Commission) and NHPC. MOH will develop a plan for the production of Human Resource for Health and share with training schools.
  • Recruit registered health professionals based on professional qualifications and experiences.
  • Ensure a good spread of quality staff in both rural (with appropriate attractive incentives for rural living) and urban areas
  • Ensure that all staff in the public sector receive regular salary in line with civil service and living standards

• Introduce short courses on ethics and discipline for all staff and ensure that staff enroll in them
  • Review Staff Operational manual based on current information on ethics and disciplines
  • Enforce ethics and discipline at all times without prejudice
  • The HRD will work in close collaboration with NHPC in carrying out its regulatory functions.

4.4             Financing health services

Part of good governance is for government to assume the responsibility of providing quality health care to its population. However, at the moment, government contribution is unable to finance the delivery of such services to its population without additional contributions either from government or elsewhere.

Policy Objective:

1. To encourage and attract additional government allocation to the health sector so that quality health services can be provided to its population sustainably;
2. To look for new innovations of attracting funds both from the public and private sources;
3. To seek additional funds from donors while reducing dependency on them.
4. To generate contributions from the community and from Somalilanders in the Diaspora;
5. To levy user fees at the point of service utilization; and
6. To explore opportunities for possible health and social insurance scheme

Policy Strategy:

It is part of good governance for government to abide by the national constitution and provide free quality services for all, as long as there is sufficient revenue to carry out this task. However, given the current fiscal situation in the country, Government will look to fund the health sector for the following financing strategic options:

Basic principles:

The funds raised locally from the communities will be invested locally to improve working environment and client comfort so that communities can see the fruits of their contributions.

As part of sustainability strategy, government shall pay attractive basic salary to all service providers working in Public facilities. Partners /agencies supporting the public health  facilities  shall  be  phased  out  of  ―topping  up‖  of  basic  salary  and  this  type  of support from the partners will be provided as incentives based on performance/ merit. Government shall gradually study this performance-based system, improve on it and customize it to the local context.

With regards to the EPHS and the issue of government counterpart funding, government shall take into account its pre-EPHS investment in the health sector that allows EPHS to be  conceived  and  considered  for  implementation  ―ab  initio‖.  This  will  include  the investments in infrastructure, equipment, supplies, past and on-going staff salary and personnel emoluments, etc.

4.1             Partnership

Production and maintenance of the health of the people is a joint effort of all including government, private, CSO/NGOs, faith-based organizations, etc. Hence, partnership is seen as the bedrock of this health policy and total participation of government and non- government forum will be highly preserved. In addition to the Regional and District Health Committees and Boards, this policy supports the emergence of committees for every health facility in the country to ensure their representativeness.

Policy Objectives

1. Ensure community involvement, participation and co-management of the health facilities
2. Provide an enabling environment for private investors to participate in joint ventures with government for the public good.
3. Encourage, collaborate with and regulate the activities of CSO including NGOs, Voluntary, Religious and Community-Based Organizations, private-for-profit and Professional Associations in the production of health care services in the country;
4. Enlarge the scope of discussion and inputs of International Agencies, Donors and NGOs on the country program and lead the initiative;
5. Explore opportunities for inter-sectoral collaboration, including other government Ministries.

Policy Strategy

Government authorities shall:

• Devise appropriate mechanisms for involving the communities in the planning and implementation of services and matters that affect their health
  • Promote establishment of various health facility and village health facility management committees;
  • Train the committees in the development of annual work plans to input into the health facility work plans;
  • Establish PPP ventures such as the CMS stores
  • Encourage financially capable Somalilanders utilize quality controlled private services to relief the pressure on public facilities
  • License these health facilities and ensure that services provided by these bodies are in consonance with the overall national health policy. The establishment of the NHPC will further enhance this work;

• Promote the optimal participation of these bodies in the planning, organization, operation and management of health programs and services, particularly primary health care;
  • Work closely with health professional associations, groups and individuals to strengthen their role in promoting research and other technical disciplines and in improving the quality of health practice and services;
  • Facilitate capacity building of the various categories of organizations to play their expected roles effectively and adequately; provide them with relevant information and engage them in dialogue as appropriate

• Approach Ministries of Planning and Finance, as appropriate, with a view to ensuring that health is accorded a central place in development planning and that health programs receive adequate funding;

• Approach the Agriculture, Housing and public works sectors with respect to guaranteeing food security and appropriate balance between the production of food crops and cash crops, and the provision of safe housing, drinking water and sanitation;

• Request the Education sector to participate in wide-ranging health educational activities, such as curriculum development and teaching and the propagation of health education subjects and issues;

• Provide information and communication skills to Sectors responsible for public works and facilitate the provision of primary health care and enhance the people‘s access to health services and information;

• Create awareness for measures required to protect the environment from pollution and to prevent occupational diseases and injuries; and shall encourage and facilitate the implementation of such measures;

• Additionally, the industrial sector shall be encouraged to consider the possibility of establishing industries for the production of essential foods and drugs

• Develop modalities and institutionalize appropriate processes for the effective coordination of international agencies and NGOs operating in the health sector;
  • Collaborate with United Nations agencies, international, multilateral, bilateral and donor agencies and institutions, regional and sub-regional organizations, to coordinate and optimally mobilize and harness their support and assistance in the health sector;

4.5   Monitoring and evaluation

Government shall continue to develop and operationalize a practical monitoring system in order to demonstrate to stakeholders the achievements and challenges; and thereby continuously improve on the efficiency and effectiveness of the entire health care system. The government shall also recruit competent professionals to support the implementation of the system at all levels of operation (Central, Regional and District). Furthermore, government shall support the training of staff at all levels in the use of the national indicators, the tools and how to analyze data for decision making.

4.5.1   Policy objective

(a) To promote the generation of data and use of evidence for decision making, program development, resource allocation and management.

4.5.2   Policy Strategies

In order to achieve the above objective, Government shall:

• Strengthen the capacity of the MoH and stakeholders to monitor and evaluate all health development interventions;
• Strengthen and ensure support for the HMIS at all levels through increased investments;
• Strengthen disease surveillance at national, regional, districts and community level;
• Increase the training, recruitment and deployment of required human resource for effective data management and dissemination at central, regional and district levels;
• Facilitate the establishment and operation of a community based health information system;
• Ensure dissemination of information to other stakeholders for purposes of improving management, sharing experiences and upholding transparency;
• Generate through periodic surveys, appropriate data for effective planning, management and delivery of health services to people with disabilities;
• Strengthen capacity for coordination and monitoring and evaluation of different stakeholders; and
• Strategy for utilization of data.

4.6             Strengthen the National HMIS system

Government shall continue with the expansion and strengthening of the national health information system. It shall be used as a management tool for informed decision making at all levels of health care and related services to:-

There shall be five levels of responsibility in the System as follows:

1. Community Level;
2. Facility Level;
3. District Level where the District Authority shall be responsible for:
4. The collection, analysis, utilization and dissemination of data in its area of jurisdiction;
5. Ensuring timely forwarding/sharing of data to and with relevant departments, agencies and programs operating at the district level;
6. Ensuring the forwarding of aggregated data and signed prescribed forms to the State level;
7. Ensuring immediate submission of data in epidemic diseases to the Surveillance Division of the Department of Public Health of the Central Ministry of Health; and
8. Training and supervision of relevant units of the health facilities within its area of jurisdiction.

• The Regional Level where the Region Health Office shall be responsible for:
• Collecting and aggregating relevant health data and information from all Districts within the Region;
• Ensuring timely forwarding/sharing of data to and with relevant departments, agencies and programs operating at the Regional level;
• Ensuring immediate submission of data in epidemic diseases to the Epidemiology Unit of the Department of Public Health of the Central MOH;
• Ensuring the preparation of a Regional Health Profile for decision making, dissemination feedback; and
• Training and supervision of Regional health facilitators and District officials.

• National Level where the Central Ministry of Health shall be responsible for:-
• The development, introduction and maintenance of an effective National Health Management Information System (NHMIS);

• The central coordination of the national health information data;
• Collecting, processing and presenting relevant and necessary information required, both for national health planning and for monitoring the utilization of resources in accordance with national priorities and objectives;
• Providing technical and management support to strengthen national HMIS at all levels.
• The flow and feedback paths of health data and information shall be from the community level to the national level; and

• National Health Research. Government shall promote health research, especially operational research in accordance with national priorities in order to support evidence‐based policy and intervention formulation, identification of gaps for improvement and identifying critical factors for special needs for vulnerable groups especially women and children. Particular attention will be given to how research can be used to guide the development and implementation of health promotion, disease prevention and early diagnosis and treatment through data generation, analysis and interpretation.

4.7.1   Policy Objective

To create a sustainable science culture in which health research plays a significant role in guiding policy formulation and action to improve the health and development of our people.

• Policy Strategies. In order to achieve this objective the Government shall:
• Put in place a policy and legal framework to ensure effective coordination of research activities.
• Develop and implement a prioritized national health research agenda in a consultative manner and undertake effective dissemination of research findings.
• Ensure adequate allocation of funds to enable the conduct of highly relevant and quality research.
• Promote dialogue and information sharing between the policy makers, researchers, health care providers and communities in order to ensure that research is relevant to the needs of the people and that research findings are utilized by the relevant stake holders, and are consistent with NHP II.
• Develop an ethical code for the conduct of health research in Somaliland, promoting the safety, rights of research participants, as well as the researchers.
• Strengthen the National Health Research capacity in institutions at all levels and develop quality human resource and infrastructure to respond to essential research demands of the country.
• Harness donor funds to ensure funding of prioritized operational research to inform policy and strategy development.

4.8                Health Infrastructure

Health infrastructure comprises of building, plant, equipment (medical devices, other equipment for health facilities and IT equipment) and transport. Government shall provide the necessary resources to ensure provision and maintenance of adequate infrastructure over the next decade, with priority being given to consolidation of existing facilities.

4.8.1   Policy Objective

4.8.2   Policy strategies

In order to achieve this objective, Government shall:

• Strengthen the Infrastructure Unit with appropriate personnel to plan, procure and maintain health infrastructure.
• As a matter of priority, adequately finance renovations and maintenance programs of existing health infrastructure, in particular PHC facilities, and invest in the construction of new facilities and staff accommodation, targeting underserved parts of the country in accordance with EPHS calendar of events.
• Prioritize investments in buildings, equipment and transport required to operationalize the health sector priorities of this Policy.
• Standardize the medical equipment needs in terms of quantities and specifications for each level of the government health system so that all interventions and services of the EPHS of that level can be provided.
• Plan and procure medical equipment according to the agreed standards of the EPHS.
• Provide the necessary logistical support, including transport, communication and IT equipment, to establish an appropriate and efficiently functioning referral system.
• Promote and increase private sector investments in the provision of health services through infrastructural development based on complimentarity.
• Provide the infrastructure, including IT infrastructure, necessary for MoH staff to carry out its functions professionally.

• Client Charter. The role of the Client Service Charter is to ensure the provision of high quality health services that is acceptable to the clients. The Government shall educate clients on how to understand the commitments of service delivery, means of communication, ways of achieving the service standards, means of correction of mistakes and on how to claim their rights.

Ø The right to highest attainable level of health

• The Constitution guarantees rights of access for all people in Somaliland to high quality health care services.
• Patients have the right to information about diagnosis, treatment, cost of treatment and consent after obtaining information and protection of privacy.

• Patients are entitled to safety in the public and private health sector. This has implications for treatment protocols, standards of medicines, medical supplies, medical equipment and infrastructure.

Communities are entitled to a healthy and safe environment i.e. access to safe and adequate water supply, sanitation and waste disposal and protection from all environmental dangers.

Ø Patients’ responsibilities

Ø Solidarity

• Government will give due consideration to pursuit of national solidarity in a common concern for health‐for‐all, with special consideration for welfare of the poor, the most vulnerable and the disadvantaged.

Ø Respect of cultures and traditions of the people of Somaliland

• All stakeholders shall respect the promotive health aspects of the cultures and traditions of the peoples of Somaliland.

• Legal Framework. One of the major weaknesses in the health sector today is the non-existence of important health legislation as well as the ambiguities of some existing health laws. Therefore, one important health legislation that government shall undertake is to put in place immediately the National Health Act which shall define the national health system and spell out the health actions of each level of government, among other things. Indeed, such an Act is necessary in order to give legal backing to this Revised National Health Policy.

5: Implementation Arrangements

The government overall strategies for implementing this National Health Policy/Health Sector Reforms will be to:

• Obtain Cabinet approval
• Disseminate the National Health Policy to internal and external stakeholders and customers. (Discuss issues such as strategic alignment, harmonization, joint analyses, management and financing of the health system, etc.)
• Disseminate the National Health policy to the donor co-ordination committee and adopt a Sector Wide Approach (SWAP). See below for details

SECTOR WIDE APPROACH

Sector Wide Approach will be premised on sufficient commitment to shared health goals by both government and donor community as key players. It will be based on the medium term national health strategic plan and the national health policy on which collaborative program of work will be developed.

Through the concept of joint funding and ―basket funding‖ the government will gradually introduce an integrated common ―basket funding‖ to encourage donors to support the Ministry of Health with ―pooled‖ financial assistance as opposed to technical assistance. This financial assistance will be paid directly into a common basket known  as ―basket  funding‖ or  ―budget support‖.   This provision of  ―un- tied‖ financial support to the Ministry of Health implies that donors will support the Health Sector by financing a single, agreed upon program with a budget administered by the Minister of Health through his Director General.

In order to successfully implement and adopt the Sector Wide Approach, the following policy measures will be implemented by the Government:

• Articulation of a well thought out and costed medium term National Health Strategic Plan;
  • An agreed upon human resource structure to implement the Strategic Plan
  • Reaching  an  agreement  on  the  prototype  ―cost-effective  essential  health package‖ for Somaliland;
  • Establishment and development of the Resource Envelope and National health Accounts respectively;
  • Development and implementation of the Financial Management System;
  • Development and adoption of the common government disbursement, procurement, accounting, auditing and reporting procedures;
  • Adoption of joint evaluation reporting, supervision and monitoring missions by Donors and MOH for appraisal, planning, programming and reviews; From this, further technical assistance will be identified and requested by the government

• Consensus by donor community on payment of per diem and honorarium (policy and guidelines to be articulated by government)
  • Introduction of common ―basket funding‖ (joint budget support).

Challenges/Barriers to Implementation of the Health Policy

In order to avert these delays, four members of the parliament will join the technical review and thus be aware of the intentions of the MOH and be part of the process in order to facilitate its approval on the floor of the houses.

• Delay in the development of the Medium term (Strategic) Plan. Securing funds from a partner/donor could lead to delays; identification of a good consultant

To avert this delay, Submit request for support to at least 2-3 partners several months before in advance

• Training of MOH staff (Central and Regional) in Annual workplan development, health accounts, Financial Accounts Management Systems (FAMS)

Identify appropriate staff and consultants ahead of schedule and ensure that there is no conflict.

4.  Several trainings, meetings, workshops, etc. all happening at the same time.

Prioritize the health policy and the MTP as a MAXIMUM alert so that staff are always available for this endeavour.

1.       Introduction

The Legal Assistance for Economic Reform programme (LASER) is a UK Department for International Development (DFID) funded programme aiming to improve investment climates in eight developing countries. LASER supports partner government initiatives that are country owned and led. One of the assumptions being tested through LASER is that international legal advice can make a significant contribution to investment climate reform. LASER is therefore supporting the leveraging of pro bono legal support – and specifically UK pro bono expertise – to developing countries, working in partnership with DFID’s Rule of Law Expertise programme (ROLE UK).

This case study looks at pro bono support provided by international law firm Slaughter and May to the Government of Somaliland in relation to electricity sector regulation. The hope is that the lessons learnt (see section 6) will be useful to ROLE UK; to legal pro bono providers; to developing country governments seeking pro bono legal assistance; and to development partners and practitioners supporting investment climate reform.

This case study has been written by LASER with input from Slaughter and May; the DFID-funded Energy Security and Resource Efficiency in Somaliland programme; DFID Somalia; and Somaliland’s Ministry of Foreign Affairs and International Cooperation.

2.       Somaliland context and background to LASER engagement

Somaliland is a self-declared independent state with a high level of fragility and a complex political environment. It has been functioning as a sovereign entity independent from Somalia since 1991 within the territorial borders of the former British Somaliland Protectorate.

Democratic elections in June 2010 brought to power a new government and enhanced international attention. In 2011, the Somaliland government (GoSML) launched its five-year National Development Plan (2012-16) requiring approximately US$150 million per year, much of which remains unfinanced. Challenges include Somaliland’s small formal sector, limited capacity for revenue collection and lack of international recognition as a state. Quasi budget support has been established in the form of the Somaliland Development Fund financed by (amongst others) DFID and Danida.

Somaliland was selected as one of LASER’s eight focus countries because it met a number of LASER’s criteria for engagement. These include the fact that Somaliland is a fragile and conflict affected state and a New Deal pilot country. There was also strong interest from the DFID Somalia Country Office (responsible also for Somaliland), an increase in DFID funding to Somaliland in recent years, and strong potential to collaborate with other donors such as the World Bank and IFC.

In October 2014 LASER undertook a scoping mission to Somaliland. The objective of the scoping mission was to meet key stakeholders and explore options for LASER engagement including initial identification of problems, partners, feasible options, and risks. At the outset of the scoping mission a number of priority investment climate problems were identified. These broadly focused on the potential transformational drivers in the economy – the energy sector, commerce, investment and industry. The scoping mission also identified the need for a LASER long-term adviser on the ground in Hargeisa, to take forward any support requested. This was considered crucial given the high risks of working in such a politically complex, fragile environment, and in order to maximise LASER effectiveness at exploring root problems and reacting to genuine demand. A resident adviser (RA) was identified and deployed to the country for one year from February 2015. The RA was embedded in the Ministry of Foreign Affairs and International Cooperation working primarily on three areas: trade, investment, and energy¹. This case study examines LASER’s work in the third area, the energy sector.

3.       The intervention – electricity regulation

The cost of electricity in Somaliland, at approximately US$1 per kilowatt, is one of the highest in the world. This is in stark contrast to rates in neighbouring countries such as Ethiopia, which is able to source electricity at approximately US$0.05 cents per kilowatt. High electricity costs in Somaliland hamper development of the manufacturing sector and establishment of enterprises, acting as a constraint on economic growth and development.

One reason for Somaliland’s high electricity costs is the lack of an effective regulatory framework or regulatory body to enable development of the sector, guide private sector operators, provide incentives for investment in the sector and support uptake of renewable energy sources. The result is a highly fragmented and inefficient sector. It is also a risk to the health and safety of consumers and employees with no health and safety standards in operation.

The GoSML has developed an energy policy including the establishment of an independent regulator

– the Somaliland Energy Regulatory Commission. A draft Electricity Act and related regulations have been developed through a USAID project in 2013, but have stalled and have been awaiting cabinet approval for the last three years. One reason for delayed action on the part of the GoSML lies with the historic ambiguity over ministerial responsibilities relating to the electricity sector and issues related to power interconnection, with confusion between the mandates of the Ministry of Public Works on the one hand and Ministry of Energy and Minerals and Natural Resources on the other.

This confusion was highlighted in LASER’s initial scoping work² and was one of the factors that led to the decision for the LASER RA to be embedded in neither of these two potential lead ministries, but instead in the Ministry of Foreign Affairs and International Cooperation (MOFAIC). MOFAIC’s strategy was to kick start activity in the sector and begin the modernisation process by leading negotiations to strike a deal with Ethiopia for the supply of cheap electricity, through accessing the latter’s hydro- power electricity. MOFAIC was not part of the inter-ministerial wrangle over responsibility for the sector: its interest in electricity regulation flowed from its proposed lead role in the negotiations with Ethiopia. MOFAIC’s intention was to set up a pilot in two towns that border Ethiopia, extending the Ethiopian high voltage grid into Somaliland. If the pilot was successful, it would be extended to other towns. The prospect of such a deal presented an immediate imperative for putting in place a legal framework to enable it to be taken forward. LASER’s RA initially supported this process by working with MOFAIC to produce an action plan for the development of the electricity sector, together with a paper setting out

the challenges involved in taking this forward. This included the urgent development of an appropriate legal framework for the sector and the setting up of a regulatory authority.

4.      Approach to obtaining pro bono assistance

The LASER RA advised the MOFAIC that to enter into negotiations with Ethiopia and take forward the pilot, specialised legal advice (not available locally) would be required to advise on the required legal framework. With no budget to contract such advice from outside Somaliland on a commercial basis, LASER’s RA drew the existence of an international pro bono market to the GoSML’s attention. The RA then supported the GoSML to develop terms of reference for the specific advice needed; and then to source an appropriate provider.

LASER considered UK law firms to have the expertise required. Although Somaliland has a hybrid legal system based on an interplay of customary law, Islamic law and initially transplanted statutory laws of European origin, pro bono suppliers from the UK have a strong offer given the focus on common law as a basis for Somaliland’s commercial law, and strong links between legal practitioners and diaspora in both countries.

Accordingly, in the summer of 2015, LASER began discussions with two potential providers pre- identified by LASER as suitable on the basis of their expertise in the energy sector, their work in the region, and their size – it was considered more likely a large firm would have the capacity to deliver the support required. The terms of reference were discussed with both firms. While both had significant expertise in energy work and in providing similar advice, it became clear during discussions that what might divide the offers of assistance, was the ability to deliver the work to the time frame and schedule proposed by MOFAIC. Slaughter and May delivered a project brief outlining where they could best add value, and detailing the level of expertise and resources they could bring to the project. Although not able to respond to every aspect of the terms of reference, they offered a team to work on the high priority areas of incorporation and structure of a national electricity company, and guidance on the development of rules and regulations. The firm also offered to respond to the request for ad hoc policy advice to senior GoSML officials in relation to energy negotiations with Ethiopia, if the need arose. The second firm offered the services of a senior specialist lawyer, but without the resources to support delivery of the work to MOFAIC time scales.

In August 2015 MOFAIC asked LASER to facilitate the engagement of Slaughter and May, who committed a team of seven staff to the project: three of the firm’s partners (all with considerable expertise in energy/regulation and Africa work), associates focusing on corporate matters, a special adviser on regulatory issues, a trainee, and its Senior Business Development Manager for Africa. Work began in September 2015, and was carried out remotely by the Slaughter and May team. In addition, LASER’s RA was able to meet the team face to face during visits to London and provide background and context to the advice required at the beginning of the process. This was followed up with regular calls once the RA was back in Hargeisa. By December 2015 Slaughter and May had delivered its advice on the legal framework necessary to take forward the pilot project with Ethiopia comprising: a regulatory framework for the pilot and for development of the sector beyond the pilot (second and third phases of modernisation); structure and articles of association for a new electricity company needed to contract with Ethiopia; and changes that might be needed to the existing draft Act and regulations in order to take the pilot forward.

5.       Results

Slaughter and May’s advice was well received by MOFAIC who considered it to be of a high standard and delivered in timely manner. The ministry states the advice means that they are now better equipped for possible electricity negotiations with Ethiopia. DFID’s Energy Security and Resource Efficiency in Somaliland (ESRES) programme who have also considered the advice consider it to be a clear explanation of how a cross border pilot could work. MOFAIC acted on it by undertaking further consultations with support from the LASER RA with private sector operators to get their input, and the advice is currently being reviewed by a Committee of Ministers established by Presidential Decree and tasked with trade and energy development. In addition, a working relationship has been established between Slaughter and May and the GoSML. MOFAIC staff who worked on electricity now have an awareness of pro bono as a potential source of expert advice, and are able to contact the Slaughter and May team direct. Slaughter and May have indicated they might be willing to continue their engagement in this sector, perhaps through a combination of pro bono and paid advice.

At the time of writing, it is too early to assess the broader impact of Slaughter and May’s advice, due to a complex and developing political situation. Since Slaughter and May’s engagement, ministerial mandates for the energy sector have been clarified, with the clear responsibility being assigned to the Ministry of Energy and Minerals (MOEM). It is not known whether MOFAIC’s strategy of attempting to ‘kick start’ modernisation of the sector through negotiations with Ethiopia was instrumental in the clarification of ministerial responsibilities.

With a new ministry responsible for energy, strategies and priorities have changed. The deal with Ethiopia and the establishment of the cross-border pilot for hydro-power is no longer an immediate GoSML priority. Instead MOEM has decided to continue with sourcing electricity from private operators (independent power providers) through diesel generators. The focus is now on putting in place a regulatory framework within this context – getting the Act and regulations passed. Support for this is being provided by DFID through ESRES. The Slaughter and May advice is framed in terms of the proposed cross border pilot, but ESRES has confirmed that the advice still has the potential to feed into the MOEM’s finalisation of the Act and regulations as:

• it makes sense for the Act and regulations to be future proofed and to ensure that they have the potential to set up the necessary structures and regulate electricity bought from Ethiopia (or another country);
• some of the advice on licensing and tariffs, although given in the context of the pilot, are more widely applicable; and
• the advice on the draft Act and regulations is sound and applicable more widely than the pilot.

More broadly ESRES has drawn on LASER’s work including the action plan, challenges paper and pro bono advice. In particular the LASER action plan has been expanded into a roadmap for MOEM.

MOFAIC and ESRES report that buying in cheaper electricity from Ethiopia is still on the table as one of several options a bit further down the line. At such a stage Slaughter and May’s advice would have more direct impact, also requiring technical advice from electricity supply and distribution experts.

6.       Lessons learnt

A number of lessons can be drawn from Slaughter and May’s pro bono assistance to the GoSML that have implications for all the stakeholders: the LASER programme, GoSML, Slaughter and May, and DFID and also for the wider UK pro bono community, other developing country governments and other donors.

Lesson 1: understanding and adapting to the political situation (which particularly in FCAS) may be rapidly changing is key to ensuring the relevance of advice provided

Slaughter and May’s advice was provided in the context of the GoSML’s intention to enter into negotiations with Ethiopia for the supply of cheap electricity, a context which subsequently changed. LASER, MOFAIC and Slaughter and May were all aware of the potential change in ministerial responsibility for energy and of the challenge of providing relevant advice in a changing context. But the prospect of negotiations with Ethiopia and the desire to press on with a long-stalled process meant that delaying the obtaining of advice was not considered appropriate. The trade-off between obtaining targeted advice on the proposed pilot on the one hand, or asking for broader support on the other and waiting for a clarification of ministerial responsibilities was also considered – and the decision taken to go for targeted, specific advice.

Lesson 2: determine what and if pro bono support is needed from the outset

Having a clear idea of the precise nature of the pro bono support required, and a pragmatic timeline for completing the work is important in facilitating both the identification of potential providers, and the eventual delivery of the pro bono assistance. The initial terms of reference drawn up by the GoSML supported by the LASER RA provided information on the background context, deliverables, and timetable and so enabled potential providers to identify whether the work was of interest and whether they had the appropriate expertise and capacity to undertake it. The terms of reference were then a useful basis for negotiations both in terms of the scheduling of assistance and refining project outputs. They enabled potential providers to understand the scope of work involved and in the case of the firm that was not selected, enabled them to understand that in this instance they did not have the capacity to provide the work needed.

Lesson 3: clear communications and a flexible approach from both the provider and client helps manage expectations and the development of a good working relationship

Slaughter and May’s project brief responded clearly to the GoSML’s terms of reference both in terms of the support they were able to provide and those deliverables that they were not able to assist with. On its side the GoSML recognised that while Slaughter and May could not offer assistance for the entire process of energy reform, the expertise it could provide in the first stages would be invaluable. Initial negotiations about the scope of assistance that Slaughter and May could provide which were facilitated by LASER were useful in terms of flagging to the GoSML that the assistance provided was pro bono, and that while a pro bono provider might fill a short term gap, pro bono providers were not willing to provide free support indefinitely.

Having a transparent discussion from the outset about the limitations of assistance and its scheduling, enabled the GoSML and Slaughter and May to foster a good working relationship that helped improve the quality of the final advice provided. For example, the mutual agreement to increase the timeframe for Slaughter and May to deliver the advice sought, meant that the team had more time to develop and tailor the advice. A good working relationship was also fostered through personal contact; Slaughter and May’s Senior Business Development Manager for Africa had initially built up a rapport with the GoSML’s Minister of Foreign Affairs & International Cooperation during an international conference.

Lesson 4: it is important to help developing country partners understand what motivates and attracts pro bono providers to offer assistance

To attract and make best use of pro bono providers, developing country clients should be aware of potential motivators for the pro bono providers – for example to develop their business, relationships or human resources. LASER was able to assist the GoSML to draft terms of reference for the required assistance which made clear that the proposed work offered providers the opportunity for direct engagement with the GoSML, and to help shape the development of an entire sector. Pro bono expertise is often sought for parcels of work but relatively rarely do providers have the opportunity to influence and develop legislation from its outset – a potentially attractive offer for a provider looking to build and expand relationships and networks within the region.

Lesson 5: the provision of pro bono assistance can involve a commitment of significant time and resources

Slaughter and May committed a team of seven professionals to the project, including three of the firm’s partners all with considerable expertise in energy/regulation and Africa work. Pro bono legal work requires the same level of resources, and be of a similar complexity to fee-paying work. Regulatory codes of conduct for legal professionals in the UK require that pro bono clients are owed the same professional responsibilities as all other clients. Pro bono providers need to factor these considerations into their decision making about whether or not to take on such work.

Lesson 6: LASER’s role as broker was key in coordinating communication between the supply and demand sides

LASER’s RA played a key role as an interface between the GoSML and Slaughter and May. The RA supported the GoSML to develop the terms of reference for the assistance; and ensured that the project was positioned as an attractive proposition to potential providers. Being embedded in the GoSML and on the ground enabled the RA to develop relationships with key officials and coordinate the working relationship between the GoSML and Slaughter and May once the work was underway. During a trip to the UK, the RA was also able to meet face to face with Slaughter and May’s team, which contributed to building their understanding of how to provide the most pragmatic advice to the GoSML, and supported the development of clear channels of communication. Somaliland law is partly based on UK statutes (in this case the Companies Act for incorporating the National Electricity Company), so Slaughter and May were able to review the Somaliland statues and produce their advice remotely. However, key to ensuring that the advice was relevant to local needs was the intelligence that the LASER RA was able to provide Slaughter and May in terms of context, priority areas and key issues for the GoSML. This meant Slaughter and May were better informed about how best to tailor their advice, and the level at which to present their guidance to ensure that it was positively received by GoSML officials.

While all pro bono interventions will not have a dedicated local representative, what this does demonstrate is the importance of communication when work is being delivered remotely. Even if a pro bono intervention does not have a presence on the ground it is important to identify, within both pro bono provider and client organisations, individuals who will take responsibility for project co- ordination and information sharing.