Rapid increase in medical schools
The study identified 112 health professions schools across Somalia (S1), with varying distribution by province. Approximately 54% of these institutions are located in Benadir, reflecting the concentration of educational resources in urban areas. However, there are schools in other states such as Somaliland (20%), Puntland (8%), South West (8%), Galmudug (4%), Hirshabelle (4%) and Jubaland (3%). has been established. Figure 1 shows the long-term growth of schools in Somalia from the year of establishment 1969 to 2023. A significant number of these schools have been established in the past decade, highlighting the recent proliferation of medical schools. Figure 2 shows the geographical distribution of schools in Somalia. This map is marked with red dots representing the 25 schools listed in the World Medical School Directory and blue dots representing schools not listed in the directory.
Figure 1
Trends in established schools over the years (1969-2023)
Figure 2
Distribution of health professional schools in each state of Somalia
Healthcare worker evaluation
The study evaluated health workers across the Benadir Regional Administration (BRA) and Galmudug, Hirshabelle, Jubaland, Puntland and South West provinces. A total of 13,236 health professionals were identified, of which 7,073 (53.4%) comprised doctors, nurses, and midwives. The remainder included clinical laboratory technicians, pharmacists, and public health workers. This workforce density is below the World Health Organization (WHO) lower limit of 2.3 skilled health professionals per 1,000 people, which is estimated to be 13 million people. This distribution shows significant urban-rural disparities, with significant deficiencies in both rural areas and metropolitan centers at the federal and state levels. This disparity highlights the need for targeted interventions to ensure equitable access to health services in all regions of Somalia.
Physicians interviewed found the educational program to be productive, particularly through the university’s partnerships with public and private hospitals in Mogadishu and a month-long community health experience in a rural area. However, they pointed to the inconsistency of existing medical rules and regulations, both in the management of service providers and patients, as well as the lack of recruitment and employment standards in these hospitals. The ratio of doctors to nurses and midwives is 1:5, but this ratio is similar in many African countries and closer to 1:3 in developed countries. This highlights the significant contribution that nurses and midwives make to the health system.
Figure 3 highlights disparities in the distribution of health professionals, with a significant concentration of health workers in the Benadir Regional Administration (BRA): 668 doctors, 401 midwives, and 1,438 nurses. It shows. In contrast, the number of health professionals in Galmudug, Hirshabelle and Jubaland is significantly lower, suggesting limited access to health services. Puntland City and South West City have medium staffing levels, with Puntland City having 210 doctors and 425 midwives, and South West City having 96 doctors and 398 midwives. The number of nurses was similar in both regions: 775 in Puntland and 743 in the South West. Table 1 shows the shortages of doctors, nurses, and midwives at different levels of the health system. According to the WHO minimum staffing standard of 23 experts per 10,000 people, there is a need for 30,000 such experts, resulting in a shortage of 20,793.
Figure 3
Regional distribution of medical professionals. (Source: Ministry of Health HRH Report (2021)
In the second scenario, adopting the WHO recommended density rate of 44.5 professionals per 10,000 population, the required health workers would increase to approximately 57,850, a difference of nearly 48,500. This shortage is further exacerbated by the inability of health departments to hire all the postgraduate health talent categories they need. Despite more doctors, nurses and midwives graduating each year, employment opportunities remain scarce in both the public and private sectors, and a policy review of public sector funding of the health sector is needed. indicates a pressing need.
Table 1 Minimum staffing standards recommended by WHO to support the achievement of UHC
Focus group discussion with young doctors
Physicians interviewed expressed dissatisfaction with employment opportunities after graduation, emphasizing the need for strong ties and family connections to secure a job. One participant said, “If you don’t have connections, it’s almost impossible to find a decent job in the medical field.” This sentiment was echoed by others who pointed to a lack of fair hiring practices. Another interviewee said, “Most of my colleagues who got the job had some connections within the hospital administration.”
Doctors noted that the private sector is similarly influenced by the need for strong ties and family connections to obtain job offers. Often the only opportunity offered is independent practice without financial reward, which many accept as professional skill development. This makes the private sector less attractive. One of the participants said that he had set up a small clinic with fellow doctors and that it was being run rationally. However, his colleagues pointed out that this employment path is only possible for a limited number of people who can afford the concrete upfront investment to set up a clinic.
The doctors interviewed said that the reasons listed above severely limit their professional opportunities, and that, as is the case for many female medical professionals, graduates often change professions and pursue fields other than medicine. She felt forced to choose between a career in business and a life as a housewife.
Employment and education awareness survey
Within two weeks, 388 students from across the country responded, expressing interest in the regulations. After excluding 35 responses from non-health-related fields, we analyzed data from 353 students, mostly from nursing (33%), public health (22%), medicine and surgery (15%), etc. I was enrolled in a priority course. , midwives (14%), medical laboratories (10%). Approximately 80% of respondents were satisfied with the quality of training. However, 56% of BRA students who responded were dissatisfied. Approximately 70% of students wish to study in Somalia, providing the basis for standardization of academic training experiences across the country.
In contrast to practicing physicians interviewed, almost 90% of students perceived their employment opportunities to be good, and 80% agreed that they would consider working in a rural area if given the chance. did. Nearly 30% of BRA and 15% of Jubaland students do not think their employment opportunities are good. However, all agreed that the existing workforce is demanding more opportunities for practical training, professional development, employment, and stricter regulation. It highlighted some of the challenges of working in a region where lack of security and terrorism prevail.
Insufficient capacity of HRH team responsible for regulatory functions
Interviewees stated that the capacity of HRH teams at both the federal and state levels was insufficient to carry out all required regulatory and non-regulatory activities. There is a shortage of team workers at both the federal and state levels. Additionally, many HRH team members lack the training they need to perform their jobs optimally. Most teams have very little budget other than salaries. That means little or no budget for communications, printing, travel, IT, and training.
regulatory framework
Interviewees stated that the lack of a functional health regulatory framework is a challenge in establishing health care regulation. They stated that the establishment of a health regulatory framework is an important milestone in standardizing professional health education in both pre-service and in-service training and practice. Interviewees said that in the past decades, the lack of a formal regulatory framework has led to lax self-regulation. Several professional groups, including medical associations, dental associations, nursing associations, midwifery associations, pharmacists, and other professional groups, work to improve access to and quality of health services and set standards for best practice. We organize our members to promote health, prevent disease, and provide medical services. Treatment and rehabilitation services in accordance with established medical sector service delivery guidelines.
These associations also each have their own interests in terms of regulation, licensure, continuing medical education (CME), continuing professional development (CPD), maintaining codes of ethics, setting standards of practice, and representing the profession in national and medical institutions. was established to protect and defend the professional interests of international level. In the absence of a binding national or state-level regulatory framework, professional associations have created autonomous systems with weak licensing powers, with little or no influence over their respective institutions’ pre-service regulations. Maintained a registration system.
There is no license exam
Interviewees stated that the credentials obtained from educational institutions serve as proxy license permits, allowing new graduates to seek employment opportunities in the health system. Neither the educational institutions nor the medical facilities that may employ these graduate professionals are registered or accredited, although most educational institutions are officially operated by the Ministry of Higher Education and/or at the competent state level. Registered voluntarily by government authorities.
Lack of continuing professional development
The study found that there is a significant gap in the professional development of health workers in Somalia due to the absence of continuing professional development (CPD) mandates. This lack of CPD requirements is further exacerbated by a general lack of training opportunities, impeding continued skills and knowledge development among healthcare professionals. However, the introduction of the National Health Professions Council (NHPC) Act marks a pivotal shift in recognizing the importance of CPD to the healthcare profession as a whole. This accreditation by the NHPC paves the way for implementing a structured CPD program, which is essential to maintaining high standards of care and ensuring health services are delivered by skilled, up-to-date professionals.
Lack of pre-service education (PSE) certification
School representatives, federal and state representatives are aware that the federal government is working closely with each state to certify pre-service education for five key executives (physicians, nurses, midwives, pharmacists and dentists). The general consensus was that each state should recognize this. Authorize pre-service training for all other executives. There was agreement on the need to harmonize all other cadres across the state to allow movement of health workers and avoid confusion. He said schools tend to largely self-regulate and have little contact with the ministries of health and education. Schools said regulatory uncertainty makes it difficult to open new schools or expand existing programs. It was also stated that because there are no standards set for the training period or abilities of each cadre, the abilities of graduates in specific occupations vary widely from school to school, creating uncertainty in the labor market.
Professional misconduct and disciplinary rights
Interviews with key informants revealed a widespread problem of corruption involving individuals known as charlatans. Fraudsters falsely pretend to be licensed healthcare professionals, especially doctors and pharmacists, when they have no official qualifications. Key informants generally recognized that dual practice, where health workers employed by public institutions also practice in private practice, was widespread and not considered problematic. . In Somalia’s health system, dual practices compensate for the low public salaries of health workers and help maintain public employment.
