HEALTH FACILITY INFRASTRUCTURE ASSESSMENT CONSOLIDATED REPORT FEDERAL REPUBLIC OF SOMALIA AND SOMALILAND TABLE OF CONTENTS Acknowledgements ............................................................................................... 2 Introduction ........................................................................................................... 3 Background ............................................................................................................ 3 Scope of the Infrastructure Assessment ................................................................. 4 Survey Implementation (Methodology) ................................................................. 4 Data Collection Tools ............................................................................................. 6 Derived Variables ................................................................................................... 9 Results.......... ....................................................................................................... 11 Comments and Recommendations ....................................................................... 49 Annex 1 - Health Facility Infrastructure Assessment Form .................................... 51 Annex 2 - Administrative Divisions of the Federal Republic of Somalia and of Somaliland .......................................................................................... 55 Annex 3 - Sample Health Facilities ........................................................................ 58 Annex 4 - List of Health Facilities .......................................................................... 95 ACKNOWLEDGEMENTS The Health Facility assessment exercise represents a significant collective achievement in improving the knowledge on the structural and functional status of the health facility network in the Federal Republic of Somalia and Somaliland. UNOPS wishes to recognize all the organizations and individuals that have supported this activity and contributed to its success. In particular: The Health Authorities of the Federal Republic of Somalia and Somaliland for their institutional support The Italian Agency for Development Cooperation (AICS) for funding the survey The World Health Organization who shared the logistics of the concurrent Service Availability and Readiness Assessment (SARA) DARS Research who organized and implemented the survey The members of the assessment teams for their dedication in often difficult situations 2 INTRODUCTION This report provides the methodology used and the results obtained by the assessment of the health facility infrastructure network the Federal Republic of Somalia and Somaliland. The survey collected detailed infrastructure data and visual documentation in each of the health facilities assessed, which provides a fairly accurate estimate of the scope of work and the costs for the rehabilitation of individual health facilities and represents the basis for the development of schematic drawings and Bills of Quantity. Annex 3 provides an example of data available for individual health facilities. BACKGROUND In 2014 to address the limited amount of information and evidence on performance of the health system, the Health Authorities of the Federal Republic of Somalia, Puntland and Somaliland, in collaboration with WHO, UNFPA UNICEF and other partners, planned the assessment of approximately 1,000 health facilities across the three zones: South Central, Puntland and Somaliland. The assessment was conducted using the standard SARA methodology to generate information on the status of health service delivery. This report provides the results Puntland. The assessment was jointly funded by JHNP, GAVI and GFATM and technically coordinated by WHO (country and regional offices) while the fieldwork and data management was sub-contracted to DARS Research, a local non-governmental organization. Since the sampling frame of the assessment was not available, a preliminary list was created using the information provided by Health Authorities and partners. The assessment aimed at generating information on selected indicators regarding health service delivery in the facilities. The results can assist the health sector of the Federal Republic of Somalia and Somaliland in assessing and monitoring accessibility of health services as well as service readiness and capacity. The SARA methodology collected a substantial amount of information on the resources and services available at health facility level but little data on the physical infrastructure component. In December 2014, UNOPS was invited to participate in a SARA planning meeting organized by WHO where UNOPS proposed expansion of the scope of the survey to include a more in-depth assessment of the physical integrity of the health facilities. This would be accomplished by adding one surveyor to each of the SARA teams to be responsible for collection of the required infrastructure data. The use of the logistic resources (in particular transportation) already deployed for the SARA considerably reduced the cost of collecting the extra information. The purpose of conducting an assessment of the infrastructure component was to provide evidence for policy, planning, and management of health system development with particular focus in the area of physical assets within the health sector. The participants of the 2014 meeting, noting that most of the health interventions included a rehabilitation component, which is often conducted without sound background information, agreed on the need of having a more comprehensive picture of the infrastructure components of the facilities and agreed, as well, on the opportunity of conducting a joint exercise. A proposal was developed in this regard and funded by the Italian Agency for Development Cooperation (AICS). 3 SCOPE OF THE INFRASTRUCTURE ASSESSMENT The scope of the assessment was to undertake a preliminary survey of the physical integrity of individual facility buildings, site conditions and services. More specifically: Site - General description of the site with photographs and GPS coordinates; Indication of locality, site boundaries (fences roads etc), dimensions, any main features such as slopes, watercourses; Site wide services - Access roads, drainage, waste water disposal, power and water supply, complementing the information already collected by the SARA tool Buildings - Assessment of the condition of the fabric of the building such as building materials, foundations, roof structure, windows, doors, etc. Deliverables The survey provided the following deliverables: The present report detailing the degree of infrastructure damage and an estimation of the cost for their rehabilitation for each district Maps showing type, location and degree of damage /rehabilitation work required of each facility A spreadsheet listing each facility surveyed with relevant indexes of damage and a preliminary estimate of cost. (It must be noted that the estimate of cost for the proposed work is a rough estimate based on a brief site assessment and viewing of photographs back in the office to try and determine approximate preliminary costs of the works. This is just to give an order of costs to assist in determining the possible next steps required for the project. The next step may be to carry out a more comprehensive survey of each facility selected for rehabilitation work with a detailed estimate of costs for the design and construction). Pictorial documentation and schematic layout for each Health Facility. SURVEY IMPLEMENTATION (METHODOLOGY) To undertake the assessment, WHO contracted DARS, a Hargeisa-based NGO. Since UNOPS intended to use the same logistics of the WHO survey team, DARS was also contracted by UNOPS to undertake the assessments. A simple assessment form was developed in order to capture the data on site (See Annex 1). A digital version of the form was developed and loaded on hand held tablet, thus facilitating data entry, -n site photographs and obtaining GPS coordinates simultaneously. It also enabled the assessment data to be synchronized to the DARS database via the internet. A 3rd or 4th year engineering student joined each of the SARA teams during the assessment missions and collected the relevant infrastructure data with a total of twenty-four teams deployed to the field. In order to familiarize the engineers with the assessment form and data collection, UNOPS undertook training of the engineers prior to the assessments. Training was held in Garowe with an engineer from the MoH participating in the training and accompanying the surveying engineers on field missions. 4 The assessment exercise commenced in June 2016 and completed by October 2016. Some of the areas were not visited due to security reasons. The data was collected by DARS and sent to the UNOPS team for data cleaning. The data cleaning exercise commenced in October 2016 and completed in November 2016. A draft report was circulated in December 2016 and several comments were received from the different State MoH on the completeness of the survey. The available list of health facilities was therefore send to the respective MoH asking to revise it and make the necessary corrections. Feedback was received only from the MoH of Puntland and of Galmudug and was used to revise the report accordingly. 5 DATA COLLECTION TOOLS UNOPS developed an ad-hoc questionnaire for collecting information on the health facilities physical infrastructure (see Annex 1). The tool contains the following sections: General