Dallow, SOMALILAND — Twenty-year old Safia Ali Abdi had never been to the doctor before she lined up at a mobile clinic under an acacia tree one October morning this year. She left her home at 7am, carrying her five-month old son Sakaria in her arms along a four-hour walk to seek care. Both their mouths had been sore and bleeding, which made it hard for Sakaria to breastfeed.
When Abdi arrived, she found three nurses and a midwife, with a line of patients waiting. The clinic was comprised of two tables, now stacked with medicine, scales to measure body weight, a wooden block for measuring height, and a tent for the midwife to examine pregnant women and new mothers. Abdi and her son were diagnosed with stomatitis, a condition that causes sores and swelling in the mouth. They were given zinc tablets and anti-fungal oral drops, and sent home.
Abdi is a pastoral nomad, used to moving throughout Somaliland with the family’s flocks. But their lives changed drastically four months ago when 100 of her 120 sheep and goats died amid an ongoing drought. In better times, her family would breed the livestock, slaughter some, and sell others to buy food in the market. Now the remaining animals are too stressed from the drought to breed or produce milk. Her family is slowly selling off the remaining livestock to buy white rice — all they currently eat.
Nurses asked Abdi to bring her son back to the clinic when it visits her area again in a month. The young mother, however, is unclear where her family will be by then.
“You could very well see a village that has 200 people this week, but next week it has 50 because it’s a nomadic-based village and they’ve all gone to find water,” said Dorothy Francis, acute watery diarrhea, drought and food security operations manager for International Federation of Red Cross and Red Crescent Societies Somalia Country Office.
Nomadic communities like Abdi’s are among the most challenging populations to reach with consistent health care. The World Health Organization estimates that there are at least 400 million people who lack access to at least one or more essential health services, leading to scores of preventable deaths worldwide.
Mobile clinics are one of the primary strategies to fill those gaps here. The Somali Red Crescent Society, supported by the IFRC, operates 33 mobile clinics to provide communities with basic health services in remote regions of Somaliland. To track the roving communities, they use a patient record system. They have built a network of community members who will keep them in the loop as the nomads move. Finally, the SRCS and IFRC are working to explain the challenges to donors, who often demand more precise accounting than is possible with populations in flux. The mobile teams are reactive to the needs of the community, and can reach patients in areas that lack vehicle or ambulance services.
he SRCS mobile clinic efforts are a step above what other Red Cross societies are doing in other nations, said Kwame Darko, health delegate to the IFRC Somalia Country Office.
“Most national societies could respond to health emergencies by mobilizing volunteers, but not mainly on a consistent basis like the SRCS is doing with the mobile and static clinics,” he said.
The intervention may provide insights for countless other mobile and hard-to-reach communities, as United Nations member states push for universal health coverage as part of the Sustainable Development Goals. The goals call for quality essential services and access to medicines and vaccines, without putting patients at financial risk.
“The mobile clinics have become the main vehicle for getting to the hard-to-reach societies,” said Francis.
Hard to reach
Somaliland unilaterally declared independence from Somalia in 1991, creating its own government institutions, police force, and currency. Its independence is not recognized internationally, however, and therefore has limited access to international funds that could help build health infrastructure, said Francis.
The tight government budget prioritizes security, including its armed forces and police, leaving only 4 percent of the budget to health, said Ahmed Bakal, Somaliland coordinator for the SRCS. For its part, the Ministry of Health exhausts much of its resources funding hospitals in urban areas, leaving remote areas underserved. The SRCS uses both stationary and mobile clinics to help with unmet needs. It acts independently, but provides supplementary care that is coordinated by the government.
The mobile clinic that came to Dallow targets a population of 6,000 when it visits under the acacia tree each month. As a whole, the mobile unit reaches over 29,000 people each month, moving from village to village, sometimes offering clinics in two places per day.
When the health team arrives in a village, they set up wherever there is space, often under a tree or inside a hut. The nurses weigh children, check pregnant women for anemia, take patient blood pressure, and diagnose acute conditions, often giving out medicine. If a child needs an IV, the drip is hung from whatever is available, be it a tree or a hut roof.
Mobile teams can follow as the population moves, adjusting their location, said Hussein Mohammed Osman, branch secretary for the SRCS Berbera Branch. The SRCS uses community volunteers, often nomads themselves, who check in with the SRCS through their mobile phones, informing the health workers about the community’s plans to move to find water.
“The [SRCS] branch has a good idea most times what their caseload is going to be, depending on the time of year, depending on what sort of rain they’ve gotten,” said Francis.
The mobile teams are reactive and responsive to the needs of the populations, she said. “If they need to provide oral rehydration sachets in a cholera outbreak, they find the hot spots and they can do that. If there is a measles outbreak, they find the hot spots, get the support they need, and respond,” she said.
Since July, as a food crisis in the region has deepened, mobile clinics have included a nutrition specialist. This specialist determines whether a child is malnourished and then provides them with enough packs of nutrition supplements to last until the next time the clinic visits the area. UNICEF has estimated that 1.4 million children will need treatment for acute malnutrition in Somalia this year.
Nomadic populations find out about the clinics through “social mobilizers” — volunteers in the communities trained to spread the word through phone calls, home visits, and community meetings.
Mobile clinic services are free, preventing patients from having to take on a financial burden for care — one of WHO’s key principles of universal health coverage. For many of those that the SRCS serves, paying would rule out seeking health care, said Darko. Abdi, for example, told Devex she would not have come to the clinic if the treatment wasn’t free.
Continuity and accountability
The clinics, of course, have their limitations — for example in emergencies, situations that require complex procedures, or even maternal health care.
Muna Juma Elmi, a midwife with one of the mobile teams, offers pregnant women her telephone number and asks them to call her when they go into labor. If she is nearby, Elmi rushes to the home with her delivery kit, she explained to Devex.
But if the patients have moved, and Elmi is far from their home, she may take time to reach the woman in labor. If she can’t make it personally, Elmi calls for an ambulance. If the woman is in an area not accessible by car, Elmi is driven as far as the car will go, and then she walks to the woman. But delays could lead to complications in the delivery.
Understanding the health history of a nomadic patient can also be tricky. SRCS provides patients with health cards that detail their basic information. The goal is to ensure that their visit to a health worker is a continuation of previous care, said Faisal Farah, health officer for the SRCS Berbera Branch. For example, if a patient is taking medication but moves to a new location, a new clinic could help ensure continuity of access. Farah says the records are largely effective, although some patients forget to carry them to visits.
The constant turnover of people also makes it harder to check back in with individuals to evaluate if the aid given to them was effective. Francis said it has been important to be upfront with donors about this challenge, ensuring they accept the ambiguity of the circumstances.
“It’s not the easiest operation to be accountable,” she said. “But we are able to demonstrate that the process is there.”
Funds for the mobile clinics are not stable, said Kaltun Hussein, national health officer for the SRCS. Funds are currently coming from the Icelandic Red Cross, the Finnish Red Cross, and the Swedish Red Cross. Money from IFRC’s emergency appeal in response to the drought is also supporting the mobile clinics.
Mobile services are expected to become increasingly important as the food crisis deepens in the Horn of Africa. The Deyr rainy season, which runs from October to December, is expected to be below average for the fourth year in a row. This may push 2.3 million people into crisis conditions, and another 800,000 into emergency conditions, according to the Famine Early Warning Systems Network.
As the crisis moves forward, the mobile clinics are an effective use of funding to reach broader populations and more investment should be funneled into their operations, said Darko.
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