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Photo story: Improving quality of healthcare in Somaliland

13 November 2023

King’s Global Health Partnerships is supporting the Ministry of Health Development in Somaliland to establish a National Quality Improvement Programme (NQIP) to improve the quality of the healthcare system, serving a population of 4.2 million people.

WHO hospital assessments pharmacy Somaliland

In partnership with Qatar Charity, the Ministry of Health Development (MOHD), THET and the World Health Organization, this two-year project is laying the foundations needed to transform the quality of care that patients receive, leading to better health outcomes for all.

In previous years the Ministry of Health has focused on ensuring the availability of health services in the country, at the community, primary, and hospital level. We are now working to improve the quality of these services.– Dr Mustafa Mohammed Ahmed, Director of Health Services and Hospitals at the Somaliland Ministry of Health and Development (MOHD)

Doctor on her ward checks a mother and baby in Somaliland — Ward round at Boroma Teaching Hospital

KGHP is working with Somaliland’s Ministry of Health Development (MoHD) to develop a national strategy to address the key, underlying causes of poor-quality healthcare. By the end of the project, all of the country’s regional hospitals will have better systems, and a more skilled workforce with the knowledge and skills to improve the quality and safety of healthcare for their patients.

Infection Prevention Control challenges in Somaliland’s six regional hospitals

Cleanliness and safety of hospitals is an area which the MoHD has identified as requiring improvement.

Infection Prevention Control (IPC) is a big challenge affecting the Somaliland health care system, as well as a lack of guidelines, policies and procedures regarding service delivery at the hospital level.– Hodan Adam Mohamoud, Head of Public Hospitals at the Department of Health Services and Hospitals, MoHD; and Strategy Lead for the National Quality Improvement Programme

Patient Handwashing station Berbera Hospital Somaliland — Patient handwashing station at Berbera Regional Hospital

Water supplies across all six hospitals are limited, making it a challenge to prevent and control the spread of infection.

Like many developing countries, we don’t have sufficient water supply at the hospital. We have a tanker to distribute water to the wards, there is no direct piping. There is always a shortage of water for handwashing, cleaning the wards, and also for toilets, so this is a great challenge.– Dr Ahmed Askar, Director of Hargeisa Group Hospital

Waste disposal at hospital in Somaliland — Waste management is a challenge in Somaliland's hospitals

“Waste should be segregated and different categories of waste placed into separate containers for disposal. This isn’t happening most of the time, mainly due to lack of staff training around the proper handling of waste.” Dr Ahmed Askar, Director of Hargeisa Group Hospital

Equipment waste disposal hospital Somaliland — Waste equipment disposed of in the grounds of a hospital

“You might find hazardous waste like biological waste put into the general waste, or find sharp materials just scattered in the spaces of the hospital.” Dr Ahmed Askar, Director of Hargeisa Group Hospital

Patients toilet block Boroma hospital Somaliland — The patients’ toilet block at Borama Regional Hospital.

A key output of the project will be the rehabilitation of handwashing and sanitation facilities, as well as the purchase of essential cleaning and waste disposal equipment needed to keep hospitals clean.

Laundry room Borama hospital Somaliland — The laundry building at Borama Regional Hospital

Since the hospital was built decades ago, the buildings and infrastructure can make it difficult to implement IPC and patient safety measures.

Inside laundry room Boroma hospital Somaliland — The laundry room at Borama Regional Hospital

“The laundry room for washing and cleaning at the hospital is supposed to have two doors – one entrance for dirty clothes and one exit for clean clothes. But here unfortunately, we only have one door for entrance and exit. We need a better building with two doors to [prevent the two loads crossing paths].” Dr Abdifatah Ileeye, IPC Officer, Borama Regional Hospital

Strengthening Somaliland’s hospitals to improve the quality of care

This project is an opportunity for the Ministry of Health to develop a national strategy; guidelines, policies, and procedures; as well as staff training, which will improve the quality of care of health services, especially focusing on patient safety and IPC, which are so important for our setting.– Dr Bashir Deria Jama, Quality Improvement Technical Lead, Ministry of Health Development

Since the project launched in April 2023, we have worked directly with the country's six, main public hospitals in Hargeisa, Berbera, Boroma, Erigavo, Ainaba and Burao to lay the foundations for improving quality of care.

Training in WHO’s Patient Safety Friendly Hospital Framework (PSFHF) and Infection Prevention Control Framework (IPCF)

In September, we ran a “Training of Trainers” course for regional hospital staff and Ministry of Health officials, on the WHO’s Patient Safety Friendly Hospital Framework (PSFHF) and Infection Prevention Control Framework (IPCF); and on how to conduct hospital assessments to monitor IPC and patient safety measures.

Quality improvement training of trainers Somaliland

Ministry of Health officials, hospital leadership and WHO experts at the quality improvement training in Hargeisa

WHO expert delivers NQIP training Somaliland

WHO expert delivers training on quality improvement and how to conduct hospital assessments on IPC and patient safety

Hospital leaders at NQIP training Somaliland

Ministry of Health officials and hospital leaders from Somaliland's six regional hospitals attended the training workshop

Hodan Adam Mohamoud (centre), Head of Public Hospitals at the Department of Health Services and Hospitals, MoHD completing the 'training of trainers' course on IPC and PSFH frameworks

Director of Berbera Hospital certificate for NQIP training Somaliland

Dr Mustafa Hussein Abdulahi (centre), Director of Berbera Regional Hospital successfully completing the training

Our main target is to train the staff from regional hospitals on how to conduct the assessments and evaluate the level of quality and patient safety in their hospitals. This will help the regional hospitals know their levels of improvement and take action steps towards quality improvement, in line with WHO guidelines and standards.– Hodan Adam Mohamoud, Head of Public Hospitals at the Department of Health Services and Hospitals, MoHD; and Strategy Lead for the National Quality Improvement Programme

Hospital assessments on IPC and patient safety

After completing the training, regional hospital staff and Ministry of Health officials, worked with the WHO experts to conduct assessments of Somaliland’s six regional hospitals, where the national quality improvement programme (NQIP) is being rolled out.

Berbera Regional Hospital, one of the six hospitals where the national quality improvement programme is being implemented

Berbera Maternal and child ward Somaliland

Maternal and child ward at Berbera Regional Hospital

Ministry and WHO officials conducting the hospital assessment at Hargeisa Group Hospital

WHO expert and doctor at hospital assessments Somaliland

The WHO and Ministry officials interview a doctor at Hargeisa Group Hospital about the challenges they face in health service delivery

The Administrator at Berbera Regional Hospital is interviewed about challenges in service delivery at the hospital

NQIP hospital assessments interview Somaliland

Hospital manager at Boroma Regional Hospital being interviewed by Ministry and WHO officials

The assessments carried out at the six, main public hospitals have identified the critical areas to prioritise, and provide a benchmark to measure improvement in IPC, better governance and policies, a more skilled workforce and improved WASH facilities. Over the course of two years, NQIP will deliver a comprehensive programme of staff training, for an estimated 700 healthcare workers (including leaders, clinical staff, cleaners and security) on preventing and controlling infection.

NQIP hospital assessments Boroma Somaliland — A health worker at Boroma Regional Hospital is interviewed as part of the facility assessment

"Assessments like these motivate staff to improve safety and accountability to patients... There has previously been poor commitment and accountability amongst healthcare providers and managers at facility levels. This programme is making us alert to the quality of care we provide for people." Hodan Adam Mohamoud, Head of Public Hospitals at the Department of Health Services and Hospitals, MoHD; and Strategy Lead for the National Quality Improvement Programme

Pharmacy at Hargeisa Group Hospital WHO assessment — WHO expert assessing the pharmacy at Hareisa Group Hospital

"This project will allow us to develop protocols and guidelines for prescribing drugs, so doctors and care providers do not put patients at risk by over-prescribing unnecessarily." Dr Ahmed Askar, Director of Hargeisa Group Hospital

We hope that this programme will improve the capacity of hospital staff, and improve the cleanliness, infection prevention control and patient safety of all of our hospitals. The resulting outcome will be improved quality of care for our patients. Patients must be safe.” – Dr Bashir Deria Jama, Quality Improvement Technical Lead, Ministry of Health Development

Other activities under the National Quality Improvement Programme

Since the project launched, we have also supported MoHD to begin planning for a National Quality Policy and Strategy to improve care across the health system. A national People's Voice Survey will feed into this, which consults citizens on their perspectives on care and allows them to contribute to setting government priorities.

Work has also begun to strengthen higher education for doctors, nurses and midwives, in order to build a stronger healthcare workforce, equipped to deliver quality of care. This component of the project will strengthen the governance of postgraduate medical education, by developing a national plan for education of medical specialists, and supporting medical schools to adopt the new national curriculum for medical education.