Polio Program Transition in Somalia: An Assessment of Risks and Opportunities - Leveraging Civil Society Resources to Scale Up Immunization

"The conclusions and recommendations have become even more important considering the large-scale disruption of immunization services, both routine and campaigns, during the pandemic."

Somalia has one of the lowest immunisation coverage rates in the world and was ranked 192 out of 195 countries worldwide for this indicator in 2018. Carried out in 2019, prior to the COVID-19 pandemic, the assessment outlined in this report focuses on the role of civil society organisations (CSOs) in the fight to end wild poliovirus (WPV) in Somalia. It was conducted by the International Federation of Red Cross and Red Crescent Societies (IFRC), based on a desk review of key documents and key informant interviews with representatives from CSOs, the Ministry of Health, United Nations (UN) agencies, and other stakeholders. The impetus behind the research was the belief that CSOs may have a role to play in helping sustain essential polio programming and other immunisation activities in light of the progressive decline in Global Polio Eradication Initiative (GPEI) funds as the world approaches polio eradication.

As IFRC explains, due to years of prolonged conflict and political instability, Somalia's health system is weak, fragmented, fragile, and underfunded. "There is a vacuum in coordination among the major health stakeholders....For example, although CSOs are a major contributor to health service delivery, some players view them as subcontractors for government supporting work implemented by other players with more funding and reach and therefore do not invite them to participate in strategic discussions. In addition, there is no active platform or mechanism for coordinating interaction among CSOs or between CSOs and other partners, which limits harmonization of strategies, information sharing, activity mapping, etc., and can result in an overlap of efforts and/or wasted resources."

The assessment revealed that Somalia's polio and immunisation programmes received US$27 million (US$15.6 million from GPEI and US$11.4 million from Gavi) in 2019. IFRC notes that the ramp-down of the GPEI polio programme funding will create a large gap in both social mobilisation and communication for development (C4D) if these activities are not integrated into broader efforts, which could, in turn, decrease activities related to generating vaccine demand and, therefore, immunisation coverage rates.

Support from CSOs is mandated in the Essential Package of Health Services (EPHS) strategy, to help make immunisation an integral part of community-level health service. According to the assessment, while individual CSOs have their own mapping data on clinics and catchment areas, there is a need for comprehensive mapping of all organisations (GPEI agencies and CSOs) down to the community level, using the polio programme asset mapping (including the Global Positioning System (GPS) data it contains) as a base.

In this context, as the GPEI funds decline, there are opportunities for CSOs to help address gaps and promote synergies between remaining polio programme activities and other health programme activities through:

• Organisation and representation - CSOs could play a role in influencing strategy crucial for effective immunisation outcomes, but the contribution of CSOs is not explicitly visible to the national government or to the major multilateral stakeholder organisations. A CSO coordination platform could help CSOs collaborate effectively among themselves and with the government and UN partners. It could be used to map facilities, services, and CSO interventions, and to help streamline reporting and information sharing.
• Advocacy support - CSOs could provide advocacy for immunisation strengthening and effective integration of relevant GPEI assets by, for example, advocating, with government, partners, and donors, for large-scale use of mobile health clinics and other outreach to hard-to-reach communities to address low vaccination coverage and, at the same time, support the government in implementing these mobile clinics. (CSO experiences in Somalia have shown that localised outreach and mobile immunisation approaches yield more community participation than fixed facilities.) CSOs could also advocate, with government, UN partners, and donors, for the introduction of home-based immunisation records, supported by a strong education campaign.
• Service delivery - For instance, because CSOs often work with vulnerable populations and usually have experiences with interventions for specific at-risk and displaced populations, CSOs could support the development of tailored tools and training of field teams on monitoring progress in certain (e.g., "last mile") populations. They could also document and disseminate existing data and interventions that could be scaled up (e.g., mobile teams/outreach services). CSOs could also support the government and UN agencies in training community health workers in the following skills: maintaining home-based immunisation records; continuing to collect real-time immunisation data; conducting defaulter tracking and community-based surveillance; and carrying out social mobilisation to create immunisation demand. On the latter: Many CSOs specialise in conducting robust social mobilisation to enhance demand, boost confidence in vaccines, and reduce the spread of misinformation. This experience could be increasingly tapped into in the future.

Recommendations include:

For Somali government and UN system (primarily the World Health Organization (WHO)/United Nations Children's Fund - UNICEF):

• Ensure that relevant GPEI assets are integrated effectively with a fully operational EPHS strategy.
• Map implementing partners to improve coordination and efficiency across the health sector. (Health- and humanitarian-focused organisations should be included in the mapping exercise and invited to join mutual coordination forums.)
• Invite CSOs from the health and humanitarian sectors to contribute more to immunisation efforts. (This could include building the capacities of CSOs, particularly in microplanning, supportive supervision, supply management, immunisation demand generation, and use of data for decision-making) and facilitating more direct links between established CSO partners and the government.)

For donors:

• Ensure that immunisation becomes a central platform for assessing programmatic progress of the country's EPHS strategy.
• Promote coordination across GPEI and Gavi to ensure full coordination of immunisation-related financial and technical support.
• Advocate for CSOs to be involved in the government and partner planning processes.

For civil society:

• Establish a CSO platform for all international non-governmental development organisations (INGDOs) and national CSOs.
• Provide advocacy support to create an enabling environment for immunisation-strengthening and effective integration of relevant GPEI assets.
• Provide technical support for specific service delivery gaps within the context of the GPEI wind down (e.g., create a user-friendly tool that could be used by community health workers to monitor children at the community level).