SIDRA Institute

SIDRA

Bridging Gaps in Healthcare: The Case for a Tertiary Hospital in Puntland

The healthcare challenges in Somalia are immense. The public healthcare sector struggles with limited resources and depends heavily on external donor support. The private healthcare, while growing, is unregulated and unable to meet the needs of a population seeking care for acute, chronic and complex health conditions. SIDRA Institute sought to examine the enabling and disabling factors of establishing a state-of-the-art private hospital in Puntland State, Somalia. This research employed a mixed-methods approach, including secondary data analysis, surveys with 106 participants through snowball sampling, and 12 key informant interviews with healthcare practitioners and policymakers. The study mapped the healthcare landscape in Puntland, which is characterized by a fragile public health system and an under-regulated private sector, alongside a growing reliance on costly medical tourism for specialized care. The study found critical deficiencies in healthcare infrastructure and service delivery, particularly in managing chronic and complex medical conditions. Approximately 31% of surveyed patients reported the unavailability of services locally, while 41% expressed dissatisfaction with the quality of care as a primary motivators for seeking treatment abroad. The economic implications are profound with the average cost of medical tourism exceeding $8,500 per patient. The study further highlights inadequacies in diagnostic capabilities and specialized healthcare personnel in Puntland State, underscoring systemic barriers to dissatisfaction and utilization of healthcare. This study proposes the establishment of a private hospital which can bring modern, specialized medical services closer to home, offering an alternative to the costly and emotionally taxing journey abroad with special focus on workforce development, improvement of regulations, and ensuring reliable medical supplies. The study concludes that a modern, private hospital has the potential to transform healthcare access and quality in Puntland State, an objective which is aligned with Somalia’s Health Sector Strategic Policy (HSSP II).

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Maritime Access and Sovereignty: A Legal Analysis of the Ankara Declaration Between Ethiopia and Somalia

The Ankara Declaration, signed on December 12, 2024, by Ethiopian Prime Minister Abiy Ahmed and Somali President Hassan Sheikh Mohamud under the mediation of Turkish President Recep Tayyip Erdoğan, marks a significant diplomatic milestone in addressing geopolitical tensions in the Horn of Africa. Emerging from months of heightened regional instability, the agreement seeks to resolve a longstanding maritime access dispute that threatened to destabilize bilateral relations between Somalia and Ethiopia and undermine regional security. This development represents a major diplomatic breakthrough following the two failed rounds of discussion since July 2024. The crisis that necessitated the agreement began in January 2024, when Ethiopia entered a controversial Memorandum of Understanding (MoU) with Somaliland, a self-declared breakaway region of Somalia. The MoU proposed recognizing Somaliland’s independence in exchange for Ethiopian access to port facilities and a potential military base. Somalia, which views Somaliland as an integral part of its territory, responded by expelling Ethiopia’s ambassador and blocking its participation in regional peacekeeping efforts, escalating tensions to critical points. The Ankara Declaration addressed three critical issues. First, it reaffirms Somalia’s territorial integrity and implicitly rejects the validity of Ethiopia’s earlier MoU with Somaliland. Second, it grants Ethiopia maritime access via Somali ports but emphasizes that this access remains under Somali authority and oversight. Third, it establishes a framework for technical negotiations aimed at finalizing commercial arrangements by February 2025 with a strict four-month deadline. While these measures signal progress toward fostering regional cooperation, they also underscore the challenges of balancing Ethiopia’s strategic interests with Somalia’s sovereignty. The Declaration’s endorsement by international actors, including the African Union (AU), the United States, and the United Kingdom, further emphasizes its significance as a potential model for conflict resolution in the region. This policy analysis examines the legal implications of the Ankara Declaration with a particular focus on its impact on Somalia’s sovereignty, territorial integrity, and Ethiopia’s maritime access. By analyzing the Declaration’s provisions, this paper explores their alignment with international law and their potential to shape future maritime cooperation between Ethiopia and Somalia.

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Towards an evidence-based and equitable childhood vaccination in fragile and protracted humanitarian setting of Somalia

Somalia is classified as the most extremely fragile country in the world (OECD, 2022).  According to OECD (2016), “fragility is the combination of exposure to risk and insufficient coping capacities of the state, system and/or communities to manage, absorb and mitigate those risks.” (OECD, 2016). A multitude of crisis, shocks and uncertainties such as persistent conflicts and violence, political deadlock, recurrent droughts and floods, and fragmented and weak state institutions have turned the country into one of the most challenging operating environments in the world and left it in dysfunctional state of fragility.   State coping capacities reflect the governance and strength of its institutions. Decades of conflict has left the state institutions with a fragmented and weak governance and decision-making structures and shortage of critical resources. The health system has particularly bore the brunt of the state collapse and suffered from fractured governance, low service availability, poor health infrastructure, severe shortage of health workers and limited reliable and quality health data. Today’s Federal Somalia accommodates two levels of health authorities; Ministry of Health at the Federal level (FMoH) and Ministries of Health at each of the Federal Member States (FMS MoH). These MoHs are responsible for leading and coordinating the health sector programmes and activities at national, state, regional and district levels. Multiple external and internal actors such as the UN agencies (WHO, UNICEF, UNFPA, World Bank) and international and local Non-governmental Organization (NGOs) are also involved in the health service planning financing and service delivery in different locations.  Poor governance, coordination, insufficient funding and limited capacity for service delivery have been idenfied as the main drivers of the ineffective planning and responsiveness, overlapping of interventions and poor performance of the health system (MoH Somalia, 2021). Somalia is one of 20 countries in the world with the highest numbers of zero-dose children (UNICEF, 2023). More than 60 percent of children under two years of age have not received any dose of the four basic routine childhood vaccines. Most of these children are in the poorest and most vulnerable segments of the population with low level of formal education and access to routine primary health care services living in remote locations and in nomadic and internally displaced communities. This brief draws evidence from two studies on zero-dose and under-immunized communities in Somalia. The first study assessed the prevalence and determinants of unvaccinated (zero-dose) children in Somalia using the demographic and health data (DHS) (Mohamoud et al, 2023). The second study explored who and where the zero-dose and under-immunized children live, and how orthe strategies used to reach zero-dose children, using the GAVI Vaccine Alliance IRMMA framework (GAVI, n.d). The overarching objective of this policy brief is to shed light on vulnerable and at-risk zero-dose and under-immunized children in the fragile context of Somalia and provide short-term as well as long-term actionable recommendations and policy options for improved and equitable childhood vaccination coverage (Bile et al, 2023). The two studies presented in this brief are part of a larger research project (RAISE) on zero-vaccine dose communities in crisis-affected populations (LSHTM, n.d).

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Transforming Lives: Empowering IDPS in Puntland with Technical Skills for Employment

Garowe hosts an estimated 8,500 households with 55,675 individuals of internally displaced persons (IDPs). War, armed conflict, insecurity and droughts, floods, and other natural disasters forced many of these IDPs to leave their places of origin, mainly pastoral areas and rural villages, and move to major urban towns and cities such as Garowe. It is estimated that around 77 percent of IDPs live in extreme poverty conditions, 10 percentage points higher than their non-displaced counterparts. Life in urban settings poses real challenges to IDPs from pastoral and rural areas, as they find it difficult to adapt their livelihood, skills, and experiences to new unfamiliar environments. The majority of IDPs rely on humanitarian assistance from the UN and International NGOs for their livelihood. This study investigated the challenges faced by IDPs in Garowe city, Puntland State of Somalia, in improving their livelihood, particularly in gaining entry to and maintaining employment.  This study adopted a qualitative research design to gain a deeper understanding of the underlying dynamic and complex factors that affect the livelihood, skills, and employability of IDPs and the multilevel barriers that they face in accessing the Garowe city job market. Key informant interviews were conducted with IDPs, mainstream public service officials, representatives of the private sector, and experts on protracted displacement. Secondary data were reviewed and analyzed to synthesize existing knowledge about employment opportunities and the demand for skills in the city. The study identified recurring themes of high unemployment, skill gaps, limited access to social networks and employers, and inadequate information and knowledge about available jobs and services among IDPs. The findings show that these significant barriers to improving IDP’s livelihood are related to lack of access to all the jobs in the labor market due to their identity and status, disparities in education and skills, and lack of resources for skills training programs to empower IDPs to acquire or develop their social and economic capital. The unequivocal importance of education, skills, and social networks appears to have practical implications for IDPs’ labor market integration. The findings underscore the need for clear government policy priority and improved access to education for IDPs and targeted skill-building initiatives as essential strategies and interventions for integrating IDPs into the labor market, thus finding durable solutions for IDPs in this protracted displacement context.

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The Clannish Dogma of Hiil Iyo Hoo: A Source of Both Order and Injustice in Somalia

This paper examines the impact of the clannish dogma “hiil iyo hoo” on justice and governance in Somalia. Rooted deeply in Somali culture, “hiil iyo hoo” emphasizes protection and social security within clans, influencing individual and group behaviors and perceptions of justice. Using multi-method approach to explore the intricate relationship between “hiil iyo hoo” and Somalia’s justice system, the study contrasts this traditional principle with Somalia’s formal justice system, imported from the West, which fails to align with these local values. The coexistence of these systems has contributed to corruption, mistrust, and political instability. The paper discusses the customary xeer-dhaqameed system, which emphasizes restorative justice and clan unity, and highlights the challenges posed by the formal system’s presumption of impartiality and independence. It also addresses issues in service delivery, exacerbated by nepotism and favoritism rooted in “hiil iyo hoo.” The paper concludes with recommendations for harmonizing traditional and modern justice systems, including the integration of Sharia law and the establishment of mechanisms to mitigate clan influences on governance.

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Determinants and prevalence of zero-dose children in Somalia: Analysis of the 2020Health Demographic Survey data

This Paper was originally published on https://journals.plos.org/globalpublichealth/ Despite global progress in childhood vaccination coverage, fragile and humanitarian countries, with high burden of infectious diseases, continue to report a significant number of zero-dose and under-vaccinated children. Efforts to equitably reach zero-dose children remain thus critical. This study assesses the prevalence and determinants of zero-dose children in fragile context of Somalia. We used secondary data from 2020 Somali Health and Demographic Survey (SHDS) to determine status of unvaccinated children aged between 12 to 23 months. Variables related to socio-demographic, household, health seeking, and community level factors were extracted from the SHDS data. Variables that were shown to be significantly associated with zero-dose children at p< 0.05 in the single logistic regression analysis were identified and included in a final multiple logistic regression analysis. A total of 2,304 women and their children aged between 12–23 months were used to determine the prevalence and determinants of zero dose children in Somalia. Approximately 60.2% of the children were zero dose children and did not receive any dose of the four basic routine vac- cines. Children living in rural and nomadic areas were more likely to be zero dose (aOR 1.515, 95% CI: 1.189–1.93). Mother with primary education and above (aOR 0.519, 95% CI: 0.371–0.725), those who attended antenatal care (aOR 0.161, 95% CI: 0.124–0.209) and postnatal care (aOR 0.145, 95% CI: 0.085–0.245) and listen frequently to radio (aOR 2.212, 95% CI: 1.106–4.424) were less likely to have children with zero dose than with their counterparts. Majority of children under two years of age in Somalia are reported to be zero dose children. Context and population specific interventions that target vulnerable mothers and their children, in rural and nomadic areas, and from lower wealth quintile index families with no education and adequate access to antenatal and postnatal care remain critical.

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Breaking the Deadlock: Balancing Ethiopia’s Seaport Quest and Somalia’s Sovereignty in the Framework of International Law.

Ethiopia, being landlocked, considers reliable and cost-effective seaport access crucial for its economic development. Studies reveal that landlocked countries tend to be 20% less developed than they would be if they had access to the sea, partly due to higher transportation costs ranging from 50 to 260% more than coastal countries. To achieve its development objectives, Ethiopia requires “export-oriented” industrialization and increased agricultural productivity (The Ethiopian Herald, 2024). Historically, Ethiopia has relied on neighboring countries for sea access, especially since Eritrea’s secession in 1993, which cut off its primary maritime outlet. Ethiopia has since secured bilateral agreements, notably with Djibouti through the Djibouti Port Utilization Agreement. This agreement grants Ethiopia permanent rights to access the sea, use port facilities, and transit goods through Djibouti’s territory. Key provisions include exemptions from customs duties and the right for Ethiopian enterprises to operate in Djibouti’s duty-free zone. Disputes under this agreement can be settled through arbitration (Shchukina, 2024). This agreement exemplifies a successful bilateral approach that respects international norms and mutual sovereignty. In addition to the Djibouti port, Ethiopian access options include Kenya’s Moyale dry port and Somal’s Berbera port, though these routes currently lack the necessary infrastructure to support bulk shipments. Ethiopia’s need for cost-effective port access has led to aggressive diversification initiatives, resulting in an increasing number of sea and dry ports utilized by the country (The Ethiopian Herald, 2024). These efforts highlight Ethiopia’s strategic goal to mitigate dependency on a single-entry point and enhance logistical resilience. As part of Ethiopia’s efforts to expand its access to ports, it signed a port pact with Somalia in June 2018 and announced plans to jointly develop four Somali ports as part of a wider bilateral agreement to enhance political and economic cooperation. This agreement reflected Ethiopia’s regional push to warm relations with its neighbors, diversify port access, and secure its economic future (Oxford Analytica, 2018). However, Ethiopia’s recent agreement with Somaliland represents a significant shift from its previous diplomatic and strategic approaches. On January 1, 2024, Ethiopia signed a Memorandum of Understanding (MoU) with the self-proclaimed Republic of Somaliland.  The full text of the agreement remains undisclosed to public, Somaliland announced an agreement to lease land to Ethiopia for 50 years for the construction of a naval facility along its coast, in exchange for Ethiopia’s recognition of Somaliland’s statehood. Yet, ambiguity persists regarding the agreement’s specifics, including the extent of the leased area and supplementary provisions. Initially, Ethiopian authorities hinted at a multifaceted purpose for the proposed facility, encompassing both military and commercial functions. Conversely, Somaliland asserted that Ethiopia’s intent revolves solely around establishing a naval base, with Berbera port retained for trade operations. Regarding the area, the initial announcement indicated a 20-kilometre stretch of coastline for lease. But later, a prominent Ethiopian figure stated the deal’s coverage spans 20 square kilometres of both land and sea (Šturdík, S. (2024). While Ethiopia’s pursuit of diversified port access is driven by legitimate economic and strategic interests, the method of bypassing recognized international protocols and engaging with an unrecognized entity like Somaliland raises critical legal and geopolitical issues. The move could lead to significant diplomatic and regional repercussions, challenging the established norms of international law and state sovereignty. Consequently, this move has been widely criticized by the international community, with countries and organizations like China, the United States, the African Union, and the European Union expressing support for Somalia’s territorial integrity. Somalia, which considers Somaliland part of its territory, condemned the agreement as an act of aggression and referred the dispute to the UN Security Council (Shchukina, 2024). With Turkey mediating talks between Somalia and Ethiopia regarding the Memorandum of Understanding (MoU), both parties have expressed a willingness to engage in continued dialogue, despite not yet reaching an agreement. This policy brief paper aims to explore the motivations, legal implications, and geopolitical ramifications of Ethiopia’s efforts to secure diversified seaport access through Somaliland. It provides a comprehensive analysis of the Ethiopian-Somaliland Agreement, examining its impact on regional stability, international law, and Somalia’s sovereignty concerns. Additionally, the paper proposes viable conflict resolution models to facilitate a mutually beneficial solution for Somalia and Ethiopia.

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Piracy and Peril in Somalia : Economic Despair and Overfishing

This study examines the resurgence of piracy off the coast of Somalia, focusing on the Puntland region, by exploring the underlying factors contributing to its reemergence and the impacts on maritime security. Utilizing a qualitative research design, data were collected through interviews with 22 key informants, including community leaders, local fishermen, maritime security experts, businesspeople, former pirates, and government officials. This primary data is supplemented by a comprehensive literature review. Thematic analysis using TAGUETTE identified key themes related to piracy impacts and potential interventions. Findings reveal that modern pirate groups have adapted with sophisticated organizational structures and advanced technological capabilities, originating mainly from impoverished and socio-economically challenged communities. Despite international naval interventions reducing piracy incidents, the root causes such as state collapse, illegal fishing, and economic deprivation remain unaddressed. Stakeholder responses highlight successes and ongoing challenges in anti-piracy efforts. While naval forces have reduced incidents, these measures are not sustainable long-term solutions. Community leaders and former pirates emphasize addressing economic and social issues, while government officials stress the need for stronger governance and law enforcement. The study recommends a multifaceted approach beyond military interventions, including protecting maritime resources, providing alternative livelihoods, strengthening local governance, and fostering international cooperation to combat illegal fishing. Investing in community-based anti-piracy programs and regional security initiatives is essential for sustainable solutions and regional stability.

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A Paradigm Shift: The Introduction of Competency Rather Than Time Based Education Model in Somalia

In this work, we propose a complete change in direction of the education philosophy and the way educational programmes are conducted in Somalia. Somalia has been struggling – and still does – with a prolonged political and socio-economic instability that has negatively impacted on the provision of education as a whole and the way teaching and learning processes are conducted in particular. As Somalia joined EAC, it is imperative to harmonize the education system in line with the education systems across all member states to facilitate a mutual recognition of qualifications, education programmes which will result in compatible skills and training opportunities. Adopting competency-based learning will require a paradigm shift from the old content and time based educational systems to competencies-driven teaching and learning approaches. The concept of competency based education (CBE) defines the mastery of specific and measureable competencies (a combination of knowledge, skills and attitudes) that help learners fulfil their potential and succeed in the future. More specifically, CBE differs from the old traditional education model that it offers personalized learning pathways and flexible progression based on the mastery of core competencies, continuous assessments to track progress and alignment with market and industry needs. The re-structuring of the education system is not without challenges and the contributions of all stakeholders must be accommodated.

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