MASTER OF DISASTER MANAGEMENT [MDMa] Master’s Thesis 2013 Dirk Grothuesmann Gynaecologist Private Health Care Services in a Fragile Country Context Somaliland Physicians’ Perspective Supervisor: Tania Dræbel, PhD Department of International Health, Immunology & Microbiology Faculty of Health and Medical Sciences University of Copenhagen Denmark Abstract Fragile states and their complex problems are of international concern. About 15% of the world population live in a fragile country context. Fragile states are characterized by the inability of a government to provide basic functions such as security, legitimacy, governance, public health care. Frequently a vibrant, unregulated private health care sector is thriving. Information about the private health care sector is sparse. Hereby the private providers’ own perceptions about their services are nearly never heard. This study focuses on nationally accredited physicians and their private services in a fragile state (Somaliland). The objective of this study is to understand Somali physicians’ perspectives about their role and to identify opportunities for improved contribution. The methodology is based on in-depth interviews and personal observations of private facilities. Key- informant interviews provide required baseline information. The data analysis is based on a thematic analysis, compatible with a theoretical framework that is inspired by phenomenology. Three major themes evolved: Physicians’ own perceived significance of their services Access to services Health sector regulations The findings highlight the perceived importance of this sector, related to high quality care and utilization. Motivation to serve is based on both extrinsic (mainly financial) and intrinsic (recognition, appreciation, caring) factors. Intrinsic factors have perceived priority. Income is derived from customers with varying wealth, coming from all Somali speaking regions i.e. horn of Africa. Access for the poor is enabled by physicians’ own contributions, however, access for the poor remains problematic. Physicians’ activities are completely imbalanced geographically distributed (clustered in three urban settings). There is a strong perception that health sector regulations are lacking. Established regulatory bodies are not empowered. The influx of unregulated external physicians goes unchecked. ii To conclude, a uniform strategy from health care access to health care education is missing. The troublesome situation results in a huge willingness of the physicians to participate in regulatory processes. Keywords: private health care fragile countries; motivation of physicians fragile countries; quality of care fragile countries; health worker crisis fragile countries; health sector regulations fragile countries iii Acknowledgement I hereby would like to express my deep gratitude to all those who supported me in completing this thesis, especially: Elli in heaven, Schorsch on earth and to my daughter Josefine, who is distant, yet always here. Ilona and her two angels. Margit and the swans at lake silver. K&B all over and for the last time Camilla, who went. They all gave me encouragement and confidence to write this thesis. iv Dedication I dedicate this thesis to all Somalianders, with their indelible hope to have an independent country that is internationally recognized throughout the world. This wish can be reflected through the traditional Somali saying: “Ama buur ahaw ama buur ku tirso (Either be a mountain or attach yourself to one)” v Table of Content Abstract ii Acknowledgement iv Dedication v Abbreviations ix 1. Introduction and Problem Statement 1 1.1 Fragile States 1 1.2 Health Care in Fragile States 1 1.3 Somaliland example 3 1.4 Somaliland’s Health sector 4 1.5 Focus of Research 6 2. Objectives 6 3. Research methods and approaches 6 3.1 In depth-interviews with national doctors 7 3.2 Key-informant interviews 8 3.3 Simple (unobtrusive) Observations 8 3.4 Literature Research 9 3.5 Theoretical framework 9 3.5.1 Phenomenology 10 3.5.2 Phenomenological reduction 10 3.6 Data analysis 11 3.6.1 Data reduction and theme selection 12 3.6.2 Post observational analysis 12 3.7 Feasibility and ethical considerations 13 3.8 Personal background and characteristics 13 3.9 Limitations of the study 13 4. Findings of the field study 15 4.1 Participants 16 vi 4.2 Physicians' self-attributed significance 16 4.2.1 Physicians’ perceptions 16 4.2.2 Physicians’ motivation 19 4.2.3 Quality of services 22 4.2.4 Spectrum of Services 23 4.3 Access to services 25 4.3.1 Main clientele 25 4.3.2 Client demographics 25 4.3.3 Access for the poor 26 4.4 Health sector regulations 28 4.4.1 Enforced regulations 28 4.4.2 Omitted regulations 28 4.4.3 Unregulated human resource management of physicians 29 4.4.4 Demand for regulations 30 4.4.5 Regulatory bodies 31 4.5 Baseline information formal private health care sector 33 4.6 Simple unobtrusive observations 34 4.6.1 Clinics 34 4.6.2 Hospitals 35 5. Discussion 36 5.1 Physician run private health services 36 5.2 Motivation 38 5.3 Access 40 5.3.1 Access for the poor 41 5.4 Health sector regulations 44 5.4.1 Regulatory Bodies 44 5.5 Present Situation 45 6. Conclusion 47 vii 7. Suggestions for further research 49 8. References 50 9. Annexes 55 Interview guide (Annexe I) 55 Boorama Trip Arrangement 4th July2013 (Annexe II) 57 Berbera Trip Arrangement 3 July 2013 (Annexe III) 58 Transcription conventions (Annexe IV) 59 10. List of Figures 60 Figure I map of administrative regions of Somaliland 60 Figure II map of Somali speaking regions Horn of Africa 61 viii Abbreviations CT Computerized Tomography DFID Department for International Development IDP Internal Displaced People MoHL Ministry of Health and Labour MDGs Millennium Development Goals MCH Mother Child Health MRI Magnetic Resonance Imaging NGO Non-Governmental Organization NHPC National Health Professional Council OECD Organization for Economic Co-operation and Development SMA Somaliland Medical Association SSA sub-Saharan Africa UNDG United Nations Development Group USD United States Dollar WHO World Health Organization 24/7 twenty-four-seven ix 1. Introduction and Problem Statement 1.1 Fragile States Over the last two decades fragile states and their complex problems are gaining more and more international attention. Instability and the resulting problems of fragile states threaten not only their neighbouring countries; they also influence international politics and policies. Approximately 50 states are regarded as fragile and 15% of the world population including about 340 million of the world’s extreme poor are living within a fragile state context (World Bank, 2007). A standard internationally agreed definition of the term ‘fragile state’ as such does not exist. Various organizations utilize different definitions suitable to their different agendas and priorities. The Department for International Development (DFID) defines fragile states as “those where the government cannot or will not deliver core functions to the majority of its people, including the poor” (DFID, 2005); and the Development Assistance Committee of the Organization for Economic Co-operation and Development (OECD) as the “inability or unwillingness of a state to deliver services to its people, or to ensure their delivery” (OECD, 2005 cited in Oswald and Clewett, 2007). Others like the World Bank in its Country Policy and Institutional Assessment (CPIA), in their scores, emphasize on economic aspects and their impact on state fragility (World Bank, n.d.). However common sense states that the provision of adequate basic services to the population is missing. In general fragile states are characterized as deteriorating, collapsed, failing legitimacy and or recovering from a major conflict (Brenthurst Foundation, 2011, Newbrander, 2006). As a consequence public confidence and trust in governmental institutions becomes diminished. Today’s world order is very much based on alliances and on predictability of national states. This established system is endangered by violent disintegration of national-states pending between weakness and failure. These fragile states affect their neighbouring countries by hindering their further development. This is related collateral security threats and humanitarian worries are based on mass migration, coordinated and uncoordinated organized criminal activities with related violent clashes, environmental destruction and uncontrolled spread of communicable diseases (Zoellick, 2008). 1.2 Health Care in Fragile States The “Global Monitoring Report” published in 2007 by the World Bank highlights two major global concerns achieving the Millennium Development Goals (MDGs); unsolved gender inequity and fragile states with their limitations to secure a stable life for their citizen (World Bank, 2007). Fragile states are far behind reaching the MDGs. Tremendous public health concerns are faced, about a third of the deaths 1 from HIV/AIDS occur in fragile countries and a third of those who no access to save water are living there. Half of all the world’s children, who die under the age of five, do so in a fragile country context (World Bank, 2007). Obviously a fragile state is unable to provide the basic human needs, such as security, water, sanitation and foremost health care (OECD, 2008). A dramatic burden of diseases (communicable and non-communicable) with disproportionately high mortality - morbidity indicators are the consequence (Newbrander, 2006). Health services provided by governments of fragile states are generally insufficient