Health Research Development Planning Workshop for Strengthening the Fragile Somali Health System

DRAFT-1

HEALTH RESEARCH DEVELOPMENT PLANNING WORKSHOP FOR STRENGTHENING THE FRAGILE SOMALI HEALTH SYSTEM

Umeå, Sweden 31st October-1st November 2018

Dr Khalif Bile Mohamud

Contents

Acknowledgements ...... 3 1. Introduction ...... 3 2. Purpose ...... 3 3. Collaborative Research’s Core Values ...... 4 4. Objectives of the Research Plan ...... 4 5. Expected Outcomes ...... 4 6. Workshop’s Themes, Proceedings and Outcomes ...... 5 6.1. Research Planning- Theme I: Endorsing the implementation of a Five-year Research Collaborative Plan ...... 5 6.2. Research Planning- Theme II: Reviewing the Knowledge Gained and Lessons Learned from the 1st Batch Research Training Experience ...... 6 6.3. Research Planning- Theme III: Research Priority Setting ...... 7 6.4. Research Planning-Theme IV: Collaborative Research Capacity Building Training .... 9 6.5. Research Planning-Theme V: Strengthening Infrastructure for Research ...... 10 6.6. Research Planning-Theme VI: Somali Inter-university Collaboration for Research Dissemination and Translation into Policy and Action ...... 11 6.7. Research Planning-Theme VII: Options for Financing the Collaborative Research Plan ...... 13 7. Conclusion ...... 14 8. Annexes...... 16 Annex 1. The Key Priorities Reflected in the Somali Health Policy that the Health Research Need to Consider ...... 16 Annex 2. Template of Research Projects Supported through Domestic Funding or through Extra-mural Collaborative Ventures ...... 18 Annex 3. List of Trained Researchers through Somali Swedish Research Collaboration for Health and the Titles of their Research Theses ...... 19 Annex 4. Participants of the Health Research Planning Workshop in Umeå, 2018 ...... 20

Acknowledgements

The participants of this collaborative research planning workshop are extending their gratitude and appreciation to all the partner universities that have contributed to the planning and organization of this important event. The workshop has been organized with the support of the WHO-based Alliance for Health Policy and Systems Research (AHPSR), through its Executive Director Dr Abdul Ghaffar to whom we are grateful for this generous sponsorship. We are also grateful to the Epidemiology and Global Health Unit, Umeå University for hosting the workshop and providing excellent facilities and the necessary logistical and coordination support. Our appreciation goes also to the Rector of Benadir University for receiving and effectively managing the distribution of the funds allocated to the workshop as planned. We also acknowledge the special technical contribution provided by the Somali and Swedish partner universities for the successful implementation of this workshop.

1. Introduction

The partners of the Somali Swedish Research Collaboration for Health held a joint research planning workshop in Umeå, Sweden hosted by the Epidemiology and Global Health Unit, Umeå University on 31st October and 1st November 2018. All the six partner Somali universities and the Swedish universities of Umeå and Lund as well as the Karolinska Institutet, Stockholm, were represented in the workshop, which was sponsored by the WHO-based Alliance for Health Policy and Systems Research (AHPSR). This workshop followed up on a range of collaborative ventures in which the aspirations of this partnership and its relevant contribution in strengthening the weak post-conflict Somali health system was carefully analyzed and important reflections made regarding its 1,2 rehabilitation, recovery and development0F 1F The workshop also came after the completion of the first collaborative research training and implementation phase encompassing a research training programme organized for young faculty from the Somali universities and professionals from the health system, concluded in June 2018, with theses presentation in a seminar held in the University of Hargeisa (UOH).

The Research Planning workshop was preceded by internal consultation exercises in which the respective Somali universities engaged in technical discussions aimed at optimizing their participation in the Umeå, workshop and producing results to sustain this partnership’s efforts in developing strong Somali research capacity and health system strengthening that accelerates the march towards universal health coverage (UHC). The Somali participants were warmly welcomed upon their arrival in Umeå followed by an interactive and productive planning workshop, reflecting the shared commitment to revive the successful Somali pre-civil war research collaboration between Somalia and Sweden that generated a sizable cohort of Somali scholars who contributed with their gained academic expertise both at national and international level. The following is a brief outline of the workshop purpose, objectives, proceedings and the agreed upon elements for a five years’ plan for this Somali Swedish Research Collaboration.

2. Purpose

The purpose of this research workshop was to:

1 Healing the health system after civil unrest. Somali-Swedish Action Group for Health Research and Development. Glob Health Action. 2015 Mar 30;8:27381. 2 Rebuilding research capacity in fragile states: the case of a Somali-Swedish global health initiative. Glob Health Action. 2017;10(1):1348693.

3 i. Strengthen and advance the ongoing Somali Swedish research collaboration, with a focus on operational research contributing to universal health coverage, and improving the health status of the population, and ii. Create a platform and road map that will guide the academic institutions to engage in health research and offer their young professionals and faculty a sound career development and a conducive research environment enabling them to pursue meaningful research.

3. Collaborative Research’s Core Values

 Establish a great collaborative research partnership between the Swedish and Somali universities founded on dignity and mutually shared respect, where diversity is viewed as an advantage  Apply sound technical standards of research design, implementation, data analysis and dissemination  Develop trained health research professionals that are enthusiastically committed and able to bridge the gap in implementation through well-organized and duly performed research programmes  Strive to undertake priority research interventions that contribute positively to the communities’ essential and lifesaving health needs and strengthen the health system

4. Objectives of the Research Plan i. To define a set of research priorities capable of addressing the evolving Somali health system challenges and map the health research capacity and scope of the current international support ii. To design several research capacity development strategies supported by the Swedish universities to bring the Somali academic institutions and their public health systems closer together to foster action towards rebuilding the fragile health system iii. To sustain the ongoing Somali research collaboration with the Swedish universities through the development of a jointly supported and coordinated public health research strategic planning road map for capacity building and producing mutually rewarding outcomes of applied policy and practices iv. To map the health research performance in the country to see who is doing what, where and with whom and the respective effects they are generating on health system policy and operational directions v. To establish a strategy for the dissemination of the research outputs and their translation into policy and action vi. To develop concrete operational guidelines to enhance solidarity between the Somali universities in research development and bestow the Swedish universities’ technical support to this effect vii. To devise concrete guidelines for establishing local research training centers in the auspices of Somali universities

5. Expected Outcomes

The following outcomes were envisaged from the proceedings and deliberations of the workshop: i. Outline of a policy and strategic framework that brings mainstream health research into the mandate of the Somali universities as centers that produce knowledge and pursue its dissemination ii. Agreement on the scope of the Somali Swedish research cooperation for health and developing a strong technical partnership between the collaborating institutions and on ways to collectively seek cooperation linkages with WHO, the AHPSR and with other health supporting organizations that are operating in the framework of the Somali health system

4 iii. Proposal of ways to promote and implement health research collaborative ventures with the ministries of health in terms of embedded implementation research projects that aim to resolve the challenges impeding the progress of key programmatic health interventions iv. Agreement on ways to promote collective support for the allocation of university financial resources for health research development, while pursuing external resource mobilization in this direction

6. Workshop’s Themes, Proceedings and Outcomes

During the two days’ research planning workshop, eight sessions were organized, five of them conducted during the first day, while the remaining three were concluded during the final day of the workshop. Each session had two moderators who briefly introduced the subject areas under discussion and led the session proceedings to ensure that the desired outcomes were achieved. Each plenary discussion was followed by the formation of two working groups where the specifics were further discussed. The concluding remarks of the groups were presented at the session’s final plenary, where additional discussion and consensus-building efforts generated a set of deliberations that became an integral part of the stipulated plan of the Somali Swedish Research Collaboration. The following are the proceedings of the different themes and the deliberated plans for each.

6.1. Research Planning- Theme I: Endorsing the implementation of a Five-year Research Collaborative Plan

Plenary moderators: Anneli Ivarsson & Khalif Bile.

Background

The first session of the workshop focused on strengthening the ongoing Somali Swedish research collaboration for health through capacity building both of human expertise and infrastructure. The partner universities agreed on the initiative to engage the researchers from the Somali and Swedish academic institutions as well as the Somali health system institutions both at federal and state level. The planned collaborative research and its implementation was required to be fully aligned with the Somali health system development policies and strategies and respond to the research capacity needs of the Somali universities. The plan is expected to offer to the young faculty promising career development and create a conducive research environment for the academic institutions enabling them to build research capacity and effectively interface with the public health services. In this health research collaborative planning, when setting the goals and objectives of the different research projects, partners will need to take into account the existing security and socio-economic barriers and the organizational performance of the Somali academic institutions, as well as the health system capacity and population health needs and consider them all in the integrated planning process.

Deliberated Health Research Plan: Points for Action i. Develop a five-years’ research collaboration plan to create a platform that will guide the academic institutions to engage in research capacity building in close coordination with the ministries of health both at federal and state level ii. Strengthen the research governance in the context of the Somali academic and health system institutions and build the necessary leadership and management capacities for effective research collaboration iii. Promote health research to generate the evidence necessary to resolve the challenges underpinning the Somali health system and create a research intervention model where it is

possible to strengthen research capacities and bridge the knowledge action gap in the context of fragility iv. Ensure that the promulgated research plan will act as a template for designing specifically targeted research proposals to be submitted to relevant funding organizations and institutions v. Promote the underlying mutually shared vision of this research undertaking it as jointly owned by all the participating Somali and Swedish institutions, underlining the need to equitably engage in its implementation, dissemination and application vi. Acknowledge that the partner universities’ collective declaration of shared satisfaction concerning the executed one-year research training programme, which despite its prolonged duration has attracted the full support of both the trainees and the senior management of the Somali universities vii. Study the strong assertion reflected by the Somali universities with regard to the establishment of MSc training with strong research orientation and the development of PhDs training during the course of this partnership; two capacity building areas that were strongly emphasized viii. Recognize the need for recruiting and training a second batch on basic research capacity building for the Somali institutions with the undertaking of complementing it with a pilot field research interventions as a key short-term milestone to be launched in the fall of 2019 ix. Scale up inter-university research collaboration between the Somali academic institutions and promote the culture of solidarity through joint research interventions, faculty exchange, and the building of communication bridges benefiting from the existing online communication technology x. Encourage the participation of the Somali National University in this research collaborative venture, being an exclusive public sector owned university

6.2. Research Planning- Theme II: Reviewing the Knowledge Gained and Lessons Learned from the 1st Batch Research Training Experience

Background

The first batch of research trainees from the Somali universities and outcome results were discussed, amidst outlining of general appreciation by the participants in the session as well as by the Somali university leaders through their communications during the Hargeisa seminar. The need to explore opportunities for continuing human resource research capacity building was a lesson convincingly shared. This experience has generated a momentum for undertaking the research capacity building process forward as outlined below:

Deliberated Health Research Plan: Points for Action

Following plenary and group discussions, several possible capacity building prospects and topics to be considered in the plan were put forward for consideration and action as outlined below: i. Encourage the Somali universities to offer small research grants directly to researchers that have successfully concluded the first batch of the research training programme in the form of domestic funding or facilitated applications for grants from the bilateral (UN) and multilateral partners assisting the health sector. Applications targeting the “WHO Small Research Grant Scheme” and the Alliance for Health Policy and Systems Research (AHPSR) and those opportunities offered by to be considered ii. Ensure that the approved research grants are designed to establish a health system research collaboration between universities on the one hand and the Federal and/or state ministries of health on the other iii. Engage researchers from the first batch to assume the role of co-tutors for the 2nd batch of research training and as mentors during the 2nd batch field research implementation phase; or/and assume research organization and management roles such as coordinating the theses of the final- year medical and health science students of their respective universities

6 iv. Assign trained researchers to assist in the university research organization activities or assume research management roles and coordination of university annual research events in partnership with the Ministries of Health and Ministry of Education and Higher Education v. Archive and disseminate the generated research evidence and promote their practical application as context specific best practices that bridge the operational gaps of priority health programmes and undertake follow up research as necessary vi. Encourage and provide the necessary facilitation to faculty members and health system professionals to contribute with inputs to the “Somali Health Action Journal” to substantiate the universities’ involvement in knowledge dissemination vii. Explore all possible opportunities in offering Somali researchers the possible enrollment in advanced academic research training of either MSc/PhD or intermediate research training programmes viii. Improve the design of the 2nd batch research training programme based on the lessons learned from the 1st batch, putting special emphasis on the development of the research protocol and linking it to a pilot field research study of limited operational scope that allows the gaining of the necessary experience without overwhelming researchers with exhaustive field engagement ix. Explore the possibility of establishing inter-university collaborative research activities in the course of the research training implementation

6.3. Research Planning- Theme III: Research Priority Setting

Background

The need to set research priority areas that are fully aligned with the Somali health needs were emphasized. Understandably, the severely disrupted fragile health system was acknowledged while facing crucial health sector challenges. The latter include socio-economic and operational problems hindering service delivery, where operations/implementation research is expected to generate context- specific solutions and generally facilitate programme execution. The research in the defined subjects of health priority, needs to consider the equity dimensions and community participation aspects of the health system, recognize the multidisciplinary nature of health and pursue transparent and partnership- based processes in its design and implementation.

The priority setting process involves the selection of strategies focusing on ongoing or new health interventions to improve their access and utilization and hence effectively respond to the health needs of the target population. The latter is addressed through implementation research which explicitly raises the questions such as, i) what is actually happening on the ground in terms of implementation? ii) how big is the gap between the expectations of the services desired and the attained outputs? and iii) what are the underlying causes and most effective actions required to bridge this performance gap? The prioritized health areas may also include problem areas that need better understanding to streamline implementation. The research priority will also include health system and policy areas that influence health services, and health system performance. The latter fall in the domains of governance and policy aspects, delivery of health services, human resources for health, quality of care and health care financing, the social determinants of health and the private health sector regulation as well as the community dimensions of PHC. Health system research is the relevant strategy to pursue towards addressing all these public health themes, as it offers not only the opportunity to generate contextual evidence to the topics studied, but also provides lessons regarding the positive findings that could be adapted locally and by other fragile country settings that could adjust this experience to their contextual realities and needs. In the development of health research priorities, the Somali health policy orientations were reflected to serve as a relevant area for consideration (see annex 1). The below outlined public health areas of priority, are the result of the plenary briefs and observations including those of the working group discussions. These deliberations are to a great extent aligned with the key policy orientations reflected by the national health policy. However, they are known to be challenged by serious operational gaps that weaken the delivery of these health services, which is

7 why research is being advocated as an appropriate strategy in resolving the causative problems and risk factors hindering implementation both at policy and operational levels.

Deliberated Health Research Plan: Priority Topics

The selected priority health system areas for research implementation are listed below: i. Sexual, reproductive, maternal, newborn and child and adolescent health including gender equity and prevention of gender-based violence ii. Nutrition and food security and primary prevention of nutrition related illnesses and behavior change communication regarding knowledge, attitudes and practices at community level iii. Control of communicable diseases with focus on tuberculosis, malaria, HIV/AIDS, cholera and the surveillance and control of disease outbreaks iv. Control of non-communicable diseases and conditions such as cardiovascular diseases, diabetes, cancers, chronic respiratory diseases, road traffic injuries and control of neglected tropical diseases v. Access to psychosocial support for mental health disorders that assumed epidemic proportions due to the civil conflicts and the absence of organized health services, trained health workforce and the blight that these patients experience through untrained and harmful traditional healers vi. The primary health care (PHC) implementation at the community level and the feasibility of establishing community based female health workers to deliver these services to the rural households and promote local communities’ ownership of the programme vii. Undertake the establishment of demographic health surveillance within the domain of each university by selecting several rural villages in close coordination with the health authority for these to become academically and research wise connected to the universities and where teaching, research and service delivery closely converge viii. Address the key social determinants of health and their impact as direct or underlying causes of morbidity and mortality with attention to water, sanitation and personal hygiene ix. Human resource training, equitable deployment and retention including the female community health workers operating in remote and hard-to-reach rural villages and nomadic settlements emulating lessons from other countries that have successfully impacted their health indicators through trained rural based heath extension workers x. Addressing the hazards of climate change such as droughts, food insecurity, undernutrition and communicable disease outbreaks risk prevention and control xi. Health system governance and leadership aspects related to the other components of the health system and the needed levels of participation, management and performance

It is self-evident that the above priorities are fully attuned to SDG3 and aligned with the universal health coverage projected road map. To align the research with PHC services, the Demographic and Health Surveillance System (DHSS) was recommended for all the universities to be initiated by selecting rural settings where training, research and community services are combined and allowing

Charted Research Priorities and Sweden’s Development Cooperation with Somalia

During the planning workshop, the Somali and Swedish participants briefly reviewed the Strategy of Sweden’s Development Cooperation with Somalia 2018-2022. The strategy focuses on four key areas, namely: i)peaceful and inclusive society; ii) human rights democracy and the rule of law; iii) resilience, environment, climate change and energy and iv) equitable health, focusing on sexual and reproductive health and rights. The strategy also emphasizes “greater and equitable access to health and medical care focusing on women and children and greater access and respect for sexual and reproductive health and rights.”

Based on this paradigm, all the elements of Sweden’s strategy are either interdisciplinary social determinants that have a direct relevance to health or are health components that are fully aligned with

8 the stipulated Somali health sector priorities. Accordingly, health research support should be recognized as a valid instrument to enhance the efficiency and effectiveness of the of Sweden’s aid assistance to the Somali health sector. The revival of Sida support to the collaborative research for the mutually set priorities of health research will need to be explored and given the due support.

6.4. Research Planning-Theme IV: Collaborative Research Capacity Building Training

Plenary moderators: Stig Wall & Abdirashid Ibrahim.

Background

Research capacity building was reflected by the workshop participants to play an important role in generating evidence that could be put into policy and action and lead to health system strengthening and an overall improvement in population’s health. The Somali health system needs substantive improvements to bridge the enormous gaps in its service delivery, a situation strongly challenged by the insufficient research infrastructure, resource limitations and scarcity of human resource capacity for research. Capacity building is attained through collaborative partnerships, training of a critical mass of local researchers able to define the major gaps that impede health progress and devise solutions to the challenges being faced, focus on high priority health areas and undertaking operations and implementation research that are close to practice. The latter will ensure the relevance of the implemented research interventions, establish conducive research environment and build the necessary infrastructure as well as career pathways for best performing researchers to ensure continuity and its technical sustainability. Efforts are also to be made to enhance the linkages between university researchers and their counterparts at the service delivery level and ensure that the selected research projects are aligned with the SDGs with emphasis on health promotion, disease prevention and community centered interventions.

Deliberated Health Research Plan: Points for Action i. Engage health policy makers and leaders of academic institutions in directing their priority focus on health research capacity building ii. Design a set of health research priorities and identify their key performance gaps that need to be addressed through a diligently planned research to generate evidence and translate its results into policy and practice iii. Establish research regulatory, leadership and governance structures for effective research management, coordination and pursue their onward dissemination and application iv. Train faculty and other health professionals on research skills to develop a wide range of professional knowledge and engage the researchers in teaching to develop critical thinking skills amongst students from the respective Somali universities v. Attract, recruit, train and retain researchers by establishing a supportive research training environment with qualified mentorship and provide the necessary remuneration by mobilizing indigenous resources and building partnerships for research implementation vi. Build greater understanding of health research among university leaders and key health system policymakers, managers, ethics boards and key medical and allied health science professionals through briefing sessions that elucidate research necessity, organization and management, with a stress on their leadership support vii. Strengthen the efforts of the Somali universities to effectively engage in a collaborative research partnership that incorporates the planning of MSc courses jointly implemented by the Somali and Swedish universities that carry the needed technological innovation and research capacity transfer between the partner organizations viii. Undertake the evaluation of the current Somali MSc study programmes, through a duly formed Somali interuniversity committee assigned for this purpose with Swedish technical oversight and

support to assess their relevance to the vast public health needs of the country and their projected overarching goals to impart on the health system ix. Consider the design of collaborative MSc and PhD sandwich training programmes for the high performing candidates executed jointly by the Somali and Swedish universities and explore potential financing mechanisms for their implementation x. Consider the mapping of Somali research performing resources and the undertaking of teachers’ exchange programme to enable the Somali researchers to join relevant MSc courses in Sweden xi. Facilitate the membership of the public sector owned faculty of medicine and health allied science undergraduate training programme of the Somali National University in the Somali Swedish research collaboration for health (this proposal was strongly welcomed by all the participants attending the research planning workshop)

6.5. Research Planning-Theme V: Strengthening Infrastructure for Research

Plenary moderators: Lennart Freij & Mohammed Hassan Ali

Background

The Research Infrastructure to be contemplated by the Somali universities will include the facilities, resources, and services that are provided to researchers when applying for grants’ including training in writing applications. It will also include the information about the existing technical and financial support opportunities. These include the universities’ governance structures in support of research, budgetary allocations for implementation, laboratory facilities, library resources and IT facilities. Research infrastructure thus plays an important role for being necessary to undertake the development of health research and provide the instruments required to boost the undertaking of collaborative research and for enhancing researchers’ training, while facilitating communication and exchange of ideas with international partners.

Deliberated Health Research Plan: Points for Action i. Include priority research infrastructure elements in future collaborative research support projects and/or grants as an integral part of the Somali Swedish research collaboration for health ii. Develop a list of essential indicators when assessing the needs or the progress made by different Somali universities focusing on research infrastructures that will contribute to the success of this partnership and monitor their affective functioning and utilization iii. Build the academic institutions’ capacity in the fields of electronic infrastructure (e-infrastructure) and set the desirable best practices for installation and operational use, while setting the required governance frameworks for data management and utilization iv. Establish health research development partnerships amongst the Somali universities’ research infrastructure and the governmental health ministries, and allow them to access the university research infrastructure for better coordination and evidence sharing v. Recruit and train the required human capital for the established research infrastructures to ensure the investigators’ effective contribution in boosting the planned collaborative research programmes vi. Promote inter-university collaboration between the Somali universities in the domain of research infrastructure, and capacity building to facilitate infrastructure knowledge and experience sharing vii. Establish linkages between the research infrastructure facilities of the Somali and Swedish universities to explore capacity building ventures and the fostering of better communication between researchers viii. Establish university research committees, research ethical boards with clear operational guidelines to assist the establishment of a sound research implementation ix. Establish demographic health surveillance system field sites in the catchment area of each university and and pursue the guidelines for their effective operation and governance and organize interuniversity study tours to share experience

6.6. Research Planning-Theme VI: Somali Inter-university Collaboration for Research Dissemination and Translation into Policy and Action

Plenary moderators: Abshir Ali Abdi & Annika Johansson

Background

The mission of developing a Somali health journal was under discussion for the past three years during which the need of a feasible plan was presented by the Somali Swedish research collaborative teams’ consultation seminars and workshops. In principle, the realization of this mission was given adequate support. A committee was subsequently formed by SSRA to provide suggestions on the matter. The key deliberations by the committee have resulted in a strategy for the launching of a regularly published journal by the name of “Somali Health Action Journal (SHAJ) ” . The committee recomends that SSRA will host the journal in its first two years. The participants in nthe present seminar agreed to this and endorsed that it is to be later published by the Somali universities, who are the ultimate owners of the project. The Somali universities’ support to the SHAJ was collectively proclaimed, indicating their commitment to translate this strong backing into practical steps, such as creating a governance and budgetary mechanisms contributing to the advancement of the journal. The ongoing efforts exerted by the Somali universities in improving their research governance and implementation are steps in the right direction that would strengthen the foundation of the journal and the upholding of the required ethical standards. The journal will also contribute in promoting mechanisms for translating research evidence into policy to ensure its practical application.

Deliberated Health Research Plan: Points for Action i. Form an Editorial Team and nominate a Chief Editor and a co-Executive Chief Editor: for the first two years the role of the Chief Editor will be assumed by Dr Khalif Bile and co-Executive Chief Editor by Stig Wall and Assistant Chief Editor by Mohamed Ali Hassan. The journal activities will be closely coordinated by the Editorial Team consisting of: Lennart Freij, Lars Gustafsson and, Maria Emellin in addition to the editors mentioned above. A member jointly selected by the Somali universities will also join the Editorial Committee ii. Establish an Editorial Board consisting of one member each from the six Somali universities that are nominated formally by their respective universities joined by the Chief Editor iii. The Somali universities will issue an official letter asserting their readiness to extend every possible support for the successful implementation of the journal project. The board chair position will be on rotation among the Somali universities on a biennial basis iv. Formulate a Journal Advisory Panel consisting of Somali, Swedish and other international reputed scholars willing also to act as peer reviewers v. Ensure that the journal publications will include contributions aimed at advancing public knowledge, policies and operational solutions that improve the implementation of health programmes, technical guidelines, short reports from the health managers operating at the national or sub-national level that contribute to health system strengthening with focus on Somali public health issues related to SDGs including universal health coverage and primary health care and social determinants of health and experiences from other fragile conflict affected settings vi. Expedite the planning of the first articles for the journal to be launched during the first half of 2019 through the commissioning of several publications that cover a range of priority health system topics and the inaugural editorial which states the vision and mission of the journal and what it will be expected to offer to its potential readers and contributors vii. Pursue the acquisition of the Open Journal System (OJS) software offering web-hosting for the journal and creating all the necessary functions for running the journal that include web-based editorial management and manuscript tracking system and collection, peer review and editorial decision-making

11 viii. Allow the possible enhancement of the membership of Editorial Board and the Editorial Team as deemed necessary to be led by their current respective committees both with the possible enhancement of their memberships as necessary ix. Recognize the settlement of the nominal first year OJS membership cost amounting to US$ 750 and planning to obtain commitments from the Somali universities for cost sharing of this annual cost and other emerging cost implications x. Undertake the mapping of the health research performance financing in the country, to evaluate what research has been carried out, by whom, what were the roles assumed by the national public health and academic institutions and what was the financial investment made towards this end. This evaluative study is in the course of being commissioned by AHPSR to one of the Somali universities’ scholar to be implemented in close coordination with the Somali health authorities and universities xi. Encourage the first batch of Somali researchers and their mentors to bring their evaluated theses with passing grade or with distinction to a publishable level and consider their submission for the journal xii. The Make arrangements for SHAJ to be a shared platform by the Somali universities expected to become a central dissemination tool for Somali researchers, while not competing with other periodicals developed by these universities or by the other Somali public health institutions xiii. Operate the journal to encourage the forging of collaborative links with scholars from other fragile and conflict affected countries and the Somali Diaspora scholars to exchange experience through journal publications and draw lessons and evidence for their practical application xiv. Contact the public sector Somali health authorities and other academic medical and allied health science institutions to recognize the potential contributions that the dissemination of contextual knowledge has in terms of policy making or for translating the generated evidence into practice while encouraging them to submit their contributions to the journal xv. Envisage working for the journal to become a model to be shared with similar fragile settings thus, offering the unique opportunity of drawing lessons from this health research experience carried out in a fragile and conflict affected country, and widely disseminating the findings xvi. Allow the full texts or reprints of articles or related comments to be published when such information is relevant to the current fragility dynamics such as those that have predicted the imminent conflict in the pre-civil war rural community observational research in Somalia. xvii. Reach out to the AHPSR seeking the needed technical guidance and a possible support for the journal initiative

The table below illustrates the planned commissioned articles and the authors’ response.

Commissioned Articles for the SHAJ Authors 1. Why a Somali Health Action Journal? The inaugural Editorial Khalif Bile Article 2. Who published on the health and health care in Somalia during the Mohamed Hassan Ali Stig Wall past 18 years? A scoping bibliometric review based on a systematic and Khalif Bile search in databases 3. Qat among the Somalis in Sweden-KAP Dr Yakoub Aden and Halima ?* 4. Fighting Against Female Genital Mutilation in Somaliland Annika Johansson 5. Malaria epidemiology in Somalia Marian Warsame 6. Blindness in Somalia: Epidemiology & Management Abdirizak Dalmar 7. Mental health Yakoub Aden* 8. Research networking: a means of health systems in fragile states/a Stig Wall* review 9. Rebuilding Somalia’s Health Systems: Policy Options Omar Mayeh & Khalif *to be confirmed

6.7. Research Planning-Theme VII: Options for Financing the Collaborative Research Plan

Plenary moderators: Lars Gustafsson& Ahmed Khaire Gutale

Background

The effective financing health research targeted to address the priority health needs of the population can have a significant positive impact. The Somali Swedish research collaboration in the pre-civil war period was technically and financially assisted among others by the Swedish government through SIDA/SAREC support to the National Academy of Science and Arts and the Somali national university. In this collaboration, the capacity building for human resource through research training and institutional research infrastructure capacity building were key components. In the post-conflict period, the pursuit of health research by the newly established medical faculties and allied health science institutions was on a limited scale often through sporadic foreign researchers led initiatives with little or no participation from Somali institutions and scholars. Through the current research collaboration for health, the Somali and Swedish universities have, predominantly using their own resources, co-financed their planned research activities, while Sida and WHO-AHPSR have financed some of the conducted research consultations critical to the success of this rewarding collaboration.

The financing of this collaborative project has since remained a major challenge posing a serious risk to the planning and implementation of the envisaged research capacity building. The latter is of high priority for the health system in fragile states where challenging contextual realities demand evidence that could bridge the gap in implementation. In this paradigm the Somali universities have accepted to create an internal domestic research funding with budgetary resources that are modest in magnitude and scope. The need for external collaborative financial support for health research implementation remains critical, in view of the necessity of linking research to health system operations in order to improve populations’ health. It is worth noting that a great deal of health research that generates significant health impact, often requires modest financing, which corroborates the feasibility of research implementation.

Deliberated Health Research Plan: Points for Action i. Undertake actions where Somali universities will contribute to the financing of the capacity building process of their researchers by covering the expenditures necessary when external support collaborative financing has not been received, which include teacher exchange training programmes allowing Somali faculty members to benefit from short research training courses in Sweden. ii. Create the opportunity of signing memoranda of understanding between the Somali universities and their respective ministries of health to collaboratively manage and finance the establishment of DHSS field sites and related infrastructure to ensure their long-term sustainability and draw lessons for both the academic and service delivery system iii. Establish collaborative partnerships between the universities and the Federal MOH and state level ministries of health to ensure the necessary policy support for research and identify service delivery operational gaps and challenges that need to be properly understood and resolved through implementation/operations research co-financed by the local international collaborative partners and Somali institutions iv. Strengthen research collaboration between the Somali universities, including Somali National University through the implementation of joint multi-center research projects contributing to capacity building but addressing critical priority areas of the health system v. Enhance the capacity of the Somali research in developing comprehensive budgeting sections for their research project proposals to strengthen their research grant applications by clearly outlining both the direct costs i.e. personnel which may include the salary of researchers and other employees in the research project, laboratory tests, diagnostic tools, equipment, questionnaires, computers, printers, survey tools, stationary, other consumables and travel expenditures; and

indirect costs such as overhead charges i.e. laboratory, electricity, water, library and other facilities that are necessary and offered by the academic institutions to run the research project, often estimated at 5-15% of the total budget as rendered possible by the grant providing organization vi. Ensure that university research and ethics offices will ultimately review the research proposals and their budgets before submission and verify if comprehensive justifications are made for all costed item included in the study and that the calculations are right, and in full compliance with the instructions and rules of the funding organizations, knowing that research proposals are checked by both technical and financial experts from the grant offering institutions vii. Review the proposal submission process to Sida and explore the possibilities of applying for funds according due consideration to the “strategy for Sweden’s development cooperation with Somalia 2018-2022” viii. Explore the Institutional capacity strengthening opportunities offered by the Migration for Development in Africa (MIDA) project supported also by Sweden and Finland that allow the temporary transfer of Diaspora professional skills in key development sectors such as health to the Somali academic institutions, knowing that several public sector Somali ministries of health are already benefiting from this window of technical assistance ix. Encourage repatriation in close coordination and consultation with Sida, the UN International Organization for Migration (IOM) of Somali Diaspora MSc and PhD holders willing to join academic institutions of the which capacity building for training of junior faculty at home is an integral part of the MIDA project x. Explore the possibility of research funds mobilization from agencies in Sweden such as Sida (by seeking a planning meeting); Carl Bennet Kamprad Research Foundation; Erling Persson Family Foundation and the Swedish Institution or by other international organizations such as WHO, AHPSR and/or the Bill & Melinda Gates Foundation by framing a research collaborative model where health is seen as a key factor for emerging from the persistent fragility that the health sector and the country are going through and reflecting health as a peace dividend in post-conflict Somalia.

7. Conclusion

The Somali Swedish Collaborative Health Research Plan has gained valuable insight from its 1st year experience of research training to a group of young faculty selected from the six participating Somali universities. The first batch training outcomes were thoroughly evaluated by the course examiners during the June 2018 Hargeisa evaluation seminar. The Somali and Swedish participants in the Umeå planning workshop deliberated their shared appreciation and labelled it, as a successful experience feasibly executed in one of the most fragile contexts in the world. This initiative has generated the shared commitment of positively building on the progress that this partnership has made by pursuing a research capacity building pathway of human resource training and the building of health research infrastructure as a critical component of the health system research development process. The plan has also the strategic aim of linking the enhanced capacity of the Somali academic health institutions to the national and local health services’ system and strengthen international research collaborative partnerships with the Swedish academic institutions and other potential partners to speed up the recovery of the fragile health system and to effectively answer the health needs of the Somali population.

A central strategy for health research development in the framework of the Somali fragile context is to define and select those health priorities that respond to the health needs of the Somali population. In this regard, the focus is being directed on a range of interventions that include reproductive maternal, newborn and child and adolescent health including nutrition; the control of high burden communicable and non-communicable diseases including mental health. However, there is a total absence of an active research and evidence communication and dissemination platform in the Somali health system. The latter is compounded by the paradoxical misconception in certain quarters regarding the seeking of research evidence for action as a futile effort, when on the contrary,

14 research application and its adaptation to the changing local context is of high necessity. Accordingly, the plan envisages the creation of a regular research dissemination platform that would be easily and freely accessible by all the Somali academic institutions, the health professionals and the different health stakeholders and federal and state level policy makers for reflection, translation into policy and practice and for their feedback contributions. The latter is aimed to appear as an open access journal owned by the Somali universities that are members in this research collaboration venture, that could be joined by any Somali university currently engaged in the academic field and officially registered by the competent health authorities and higher education of their administrative jurisdictions.

Under this paradigm, the current research financing gap needs to be jointly addressed first by the Somali universities creating their internal mechanisms for financing research. Universities should also closely work with their national and state ministries of health to mobilize both domestic and international resource inputs targeted to research on the high burden health priorities to ultimately bridge the implementation gap between knowledge and action. Finally, the parties in this initiative fully recognize that despite the imperfect fragile context, the observed solid commitments and outcomes of the Somali and Swedish academic institutions, substantiate the feasibility of research undertaking and its operational adaptation to the local context. However, the sustainability of this initiative will be effective when health research and service partnerships are established both at the strategic and operational level. The latter will enhance health research financing opportunities that are critical for research capacity building and research translation into policy and action that lead into improved health outcomes.

8. Annexes

Annex 1. The Key Priorities Reflected in the Somali Health Policy that the Health Research Need to Consider

i. To improve access to Strengthening RMNCH and Nutrition; controlling Acute Watery Diarrhea, essential health services for Cholera and other Enteric Disease, TB, Malaria and HIVAIDS; hepatitis reducing mortality and viral infections & neglected tropical diseases; -Non-communicable diseases undernutrition, and control including mental disorders and Road Traffic Injuries prevalent communicable and non-communicable diseases ii. To develop a health Accelerating the production of midlevel health professionals; creation of workforce that is adequate community-based health workforce (FCHWs, CMWs and ACMWs); HRH in number, well trained, employment and deployment standards; improving HRH governance, equitably distributed and leadership and management capacities, motivation and retention; motivated to provide establishment of health professional associations that coordinate with MOH essential health services HRH regulation, certification, credentialing, registration, accreditation and licensing and improving the HRH information system and coordination iii. To build effective Setting legislative and regulatory norms and standards for the key functions leadership and governance of the health system and training the management cadre at all levels on that assumes the core leadership and management skills; improving public financial management; health functions and developing partnerships and coordination; Developing a health regulatory engaging the private sector framework; health system decentralization and coordination; regulating the pharmaceutical sector and food and beverages and strengthening the ongoing decentralization processes for state, regional and district authorities effective service delivery and developing guidelines that substantiate the Client Service Charter’s key principles and operational norms and educating the public to enhance their knowledge about the services provided by the health system in order to improve the populations’ care seeking behavior iv. To ensure the availability, Implementing the concept of essential medicines; training skilled quality and affordability of workforce and developing drug formularies, drug quality assurance; essential medicines, medicines’ mandated formal registration; exploring the relevance of a vaccines and commodities revolving drug fund; and undertake herbal medicines and other traditional remedies’ research to identify their beneficial effects and potential harmful impact, to educate the population about the rationale of their practical use v. To establish an effective Establishing a health system observatory to collect and analyze the HMIS health information system data; and promoting health systems and operational research, with human for evidence-based resource capacity building to assess the progress of major health planning and interventions and introducing the needed problem-solving improvements in implementation close partnership with the academic institutions and using the HMIS data and research generated evidence for policy, evaluation, planning and health services’ implementation. vi. To raise adequate funds for Increasing government budgetary allocations for health; Introducing health to protect the poor financial incentives to encourage facility-based deliveries and child catastrophic health immunization using the voucher based system or other incentives; expenditure and move promoting public- private partnership (HRH development, EPI services and towards UHC in the control of communicable diseases; exploring the implementation of community health insurance and harmonization partners’ resource mobilization for health for greater aid effectiveness and managing the contracting out related decisions through detailed memoranda of understanding, and in close coordination and joint evaluation of the outputs, outcomes and impacts vii. To bridge the gap in the Setting normative standards for the health sector infrastructure i.e. health infrastructure to buildings, equipment, technologies and the logistic support system and create an effective service pursue their rehabilitation, procurement and management; developing delivery network medical equipment policy guidelines in which standard equipment are

installed in every health care level and training the health workers assigned on their operations for their effective use and management; and establishing a management system for health technology assessment and evaluation of their cost-effectiveness and impact viii. To control public health Creating public health resilience, preparedness and strategic policy threats and reach out to operating at central, regional, district and community level and reducing affected communities with adverse health effects of encountered emergencies; introducing the concept integrated effective of disease and disaster early warning system and building the preparedness assistance targeting their and response capacities necessary; effective coordination of emergency specific public health health response interventions and mobilizing intersectoral support and emergencies community action as necessary; focusing on disease and nutrition surveillance data and their dissemination and developing emergency preparedness and response guidelines and operational standards, in terms of logistics, health workforce training, pre-positioning of essential drugs and earmarking the required contingency support. ix. To address the social Promoting action on the social determinants of health (SDH) addressing the determinants of health, health concerns related to environmental sanitation and waste disposal; emphasizing on food safety; injury prevention; poverty alleviation, gender equity, intersectoral collaboration occupational safety; school health, water and sanitation and substance and building the capacities abuse; developing public policies that create mutual gains for health, across necessary for its different sectors; promoting interventions that benefit the disadvantaged implementation. Somali nomadic population through multisectoral collaboration and active community participation; endorsing the concept of health impact assessment (HIA) to estimate possible adverse health implications of all development interventions, and building the health workforce capacity about the SDH and health equity and on the value of collaborating with other sectors and promoting research on the relationships between social determinants of health and health equity and the effectiveness of pursued policy interventions and disseminating the generated evidence among different sectors for policy consideration and action.

Annex 2. Template of Research Projects Supported through Domestic Funding or through Extra-mural Collaborative Ventures

No Project title Starting date Finishing date Earmarked budget 1 2 3 4 5 Total

Annex 3. List of Trained Researchers through Somali Swedish Research Collaboration for Health and the Titles of their Research Theses

1. Abdirahman Hersi Hassan: Prescribing patterns of medicine using WHO prescribing indicators at the Out-patient department of Galkayo South Hospital, Mudug region, Somalia. 2. Abulfatah Abdullahi Jama: The Case Load of Urological Surgery In selected Mogadishu Hospitals and Reported Post-Operative outcome from 1st January 2015 to 1st July 2015 3. Asad Ibrahim Adam: Prevalence of malnutrition and associated factors among children aged between six to fifty-nine months in Galkayo district, north-central Mudug region of Somalia 4. Ayanle Suleiman Ahmed: Psychotic condition: traditional healers and their role in dealing with khat induced psychosis 5. Bashir Dirie Jama: Knowledge attitude and perception of Somali pregnant women towards c- section delivery in Berbera town, Somaliland 6. Daud Abukar Yusuf: North Galkayo mothers’ experiences and perceptions of health education on diarrheal disease prevention - a hint about how less is more in improving the post conflict Somalia health system 7. Hamda Abdillahi: Assessment of healthcare utilization factors among women of childbearing age in, Hargeisa, Somaliland 8. Hamda Hassan Warsame: Neonatal mortality rate and its determinants in Bosaso Puntland state of Somalia - Promoting newborns survival means promoting a sense of humanity 9. Hussein Jama Had: Determining prevalence of hepatitis Bs Ag infection and associated risk factors among pregnant women and their knowledge attitudes and practices towards HB infection, Hargeisa city, Somaliland 2018 10. Jamila Ahmed Aden: Maternal Mortality in Bosaso District of Somalia: Retrospective Case Study on Causes and Contributing Factors 11. Khadra Ahmed Hassan: Knowledge, Attitude and Practices of Exclusive Breastfeeding among Mothers in Hargeisa, Somaliland 12. Mohamed Farah Abdullahi: Factor Contributing the Sub-optimal uptake of vaccination in Galkayo District, Somalia, 13. Nasir Ibrahim Said: Determinants of place of delivery among mothers in Borama district, Awdal region in Somaliland 14. Sahra Mire Mohamed: Knowledge, attitude and practice of female genital mutilation among traditional birth attendants in Mogadishu-Somalia, 15. Semira M Taher: HIV/AIDS Knowledge and Perception among young students in Borama, Somaliland 16. Yusuf A. Hareed: Knowledge, Perceptions and practices of self-medication among households in children under five years in Borama, Somaliland

Annex 4. Participants of the Health Research Planning Workshop in Umeå, 2018

Name E-mail Abdirashid Ibrahim [email protected] Amoud University, Amoud School of Dentistry, Somaliland Abdisamed Abicar Hagi [email protected] Post pediatric coordinator & executive committee, Benadir University Abshir Ali Abdi [email protected] Dean Faculty of Medicine & Health Science, East Africa University, Puntland State Ahmed Khaire Gutale [email protected] Secretary of the University Foundation (Mufed) Board, Galkayo University, Galmudug State Anneli Ivarsson [email protected] Umeå University Annika Johansson [email protected] SSRA John Kinsman [email protected] Umeå University Khalif Bile [email protected] SSRA Klasse Sahlen [email protected] Umeå University Lars L Gustavsson [email protected] Professor MD, Division of Clinical Pharmacology, Karolinska Institutet Lennart Freij [email protected] SSRA Maria Emmelin [email protected] Professor of Global Health Lund University Mohamed Hussein Aden [email protected] Dean School of Medicine, Puntland University of Health Science and Technology, Galkayo, Puntland State Mohammed Hassan Ali [email protected] Umeå University, Medical student Sied Muhumud Jibril [email protected] University of Hargesia, Somaliland Stig Wall [email protected] Professor Emeritus, Umeå University

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