A Life-line for Rural Communities: Training Community Health Workers in Somaliland

We’re driving along one of Somaliland’s main roads, an artery that cuts across the Sahil Region linking the capital Hargeisa with the coastal city of Berbera, when our driver, Abdi, makes a sharp right turn, leaving the relative comfort of the pot holed tarmac and embracing the undulating and unforgiving terra incognita of the Somaliland desert. As we hit the earth, we’re thrown about in all directions and I make use of any and all handles to support myself. A couple of minutes in and I’m starting to feel nauseous. ‘How long till we’re there?’ I enquire. ‘Two hours,’ comes the reply, ‘maybe three.’ It’s at this point that I realise the herculean task of getting an ambulance to a remote village like the one we’re visiting today, and how truly awful it must be for any sick patient taking that journey.

60% of the population in Somaliland is nomadic and many settlements and villages sit in isolated rural parts of the country. These remote communities have little or no access to healthcare and often only seek treatment when conditions take a turn for the worse. I’m visiting one such village today, Hulqaboobe, to see how THET’s Community Health Worker (CHW) programme is bringing essential healthcare to the local population.

I’m traveling with Amina Abdi, the lead tutor for the Community Health Worker programme. The programme has been developed by THET in collaboration with the Somaliland Ministry of Health and the UK Department for International Development, and takes a three tired approach: train CHWs, update the existing CHW curriculum and training manual, and deliver training to trainers who can continue to deliver the course in the future.

One of the fundamentals of the CHW programme is that students must be selected by their local community and then return back to that same community to work and provide healthcare, as Amina explains:

One of the criteria was that trainees should be selected by the health committees in their village. The person living there knows the rules and what the situation is in the community. We wanted to make sure the candidate can help their own community.

The car slows and Abdi tells me we’re in Hulqaboobe. The village is flanked by mountains on two sides and looks about as remote as you can get.  Up ahead sits a large tree surrounded by huts and a Primary Healthcare Unit, built recently by one of THET’s partners Health Poverty Action. The village elders greet us and I’m introduced to the three CHWs who will be serving the local population. I speak to one, Asiya Awiye Muhumed, about her experience on the course:

When I was selected by my society that was the first time they trusted me, and during my first visit to the village after initial training we organised a community gathering and explained about our objectives. We told them that with the knowledge we are gaining from the training we want to serve them better.

Health indicators in Somaliland are extremely poor. According to UNICEF one in every 14 children die before reaching age one while one in every 11 children does not survive to their fifth birthday; the maternal mortality ratio is 1044/100,000; and less than 50% of births are attended by a skilled attendant.*

CHWs embark on a nine month course that is broken down into six week blocks. This includes three weeks of class based study, a week working in their local health facility, and a community placement for a week, which is followed by a week of leave. Amina highlights the scope of the training:

The topics they are learning are really a lot. I can say some of the things they are learning are how to take care of pregnant mothers, how to take care of sick children, how to recognise the danger signs during pregnancy, after pregnancy, or during delivery. The healthy environment is also one of the things we are teaching them so they understand what health means and why we need to have a healthy environment, a simple example being handwashing.

The rugged beauty of Hulqaboobe village is quite stunning. The unexpectedly green landscape is broken up by orange rock and dusty earth, punctuated by the bright, vibrant colours of the Hijabs worn by local women. There is a huge crowd in Hulqaboobe today and Hersi Ahmed, one of the other CHWs selected from the village, explains that this is usual. People come from all around the area to be seen by the health workers:

Every day is like this and there are lots of sick people who need help, that is why I wanted to work for my people.

Hersi describes the impact of the training so far:

The training is going very well. We’re learning a lot of good things and Amina is supporting us to learn many things which we did not know before. We did not know how to measure BP and first aid, we knew none of these! But now we know many things.

As our time in Hulqaboobe draws to an end I grab a quick word with the village elder. I ask him what impact the CHWs will have on the community:

Before this health facility was built we used to hire a lorry to take pregnant mothers to hospital, but now we get access to ambulances, and when someone gets ill in the village we get medicine from the health centre. Initially, there was only one health worker in the facility, but now we are expecting it to be more efficient because we are going to have the Community Health Workers who are very active in the health centre. So that is huge benefit to the village people, and we are very grateful to those whose support has made this happen and all those who participated in their training. We want to continue from there and improve upon it, I hope that we continue receiving support.

The engine of our car rumbles into life behind me, signalling that it really is time to go. It’s clear from the people I’ve met today that the appetite for healthcare development is strong in Hulqaboobe.

The CHWs are providing a much needed life-line to neglected communities and I look forward to returning again when the CHWs have graduated and are in their posts to see the impact they are having on patient’s lives.

*Summary Preliminary Results Multiple Indicator Cluster Survey, 2011, UNICEF.