Health System Privatisation - A Barrier to Accessing Healthcare?

by Hayat Mohamed Yusuf

Imagine you are in your prime and all of a sudden you start to notice that your feet are swollen more often than usual. You dismiss it, as it isn't serious enough to go to the hospital, and a few months later you find you have high blood pressure which is followed by a series of strokes. Soon you lose sight from one of your eyes and become diabetic. Your condition quickly spiralled to something out of your control as the initial symptoms weren't kept in check. Yet, this is the reality for many in Somaliland. Although simple testing in the early stages could have prevented further complications, people often leave their condition until it is critical as access to healthcare is limited.

Access to healthcare, something which is largely considered to be a fundamental human right, remains a privilege for many in Somaliland. The dichotomy of progress has inadvertently established barriers to this basic human necessity. In Somaliland, the challenge of access to healthcare is starkly evident, and despite the country making significant strides in development, the health system has appeared to lag behind.

In Somaliland, many people aren’t diagnosed with diseases, such as cancers, diabetes or heart diseases until they are at their most advanced stages. In fact, according to the World Bank, in 2019, noncommunicable diseases accounted for 30% of all deaths in Somalia, and many of these deaths occur prematurely. The reasons for this are multifaceted and include economic obstacles, a lack of awareness, and inadequate healthcare infrastructure. Some argue that despite the positives the privatisation of the health system can bring, that it is also one of the leading problems contributing to the lack of health access in the region. Indeed, with private providers constituting 80% of healthcare in Somaliland, access to it has become unaffordable for large portions of the population.

Some international policymakers currently recommend greater use of private providers on the grounds that they offer consumers greater choice, increase competition in the healthcare market, and remove state responsibility for service provision - thereby encouraging its role as regulator. However, an increase in private providers can lead to concerns such as those being expressed in Somaliland, where it seems this privatisation intended to safeguard healthcare could be becoming a barrier to it.

Indeed, due to many Somalilanders living in relative poverty, family priorities can often be focussed on ensuring there is food and water on the table rather than seeking early medical intervention or diagnosis for any minor health problems they may be facing at the time. Working long hours to make ends meet and having limited resources means that even when noticing health issues, Somalilanders will often delay seeking medical attention until their condition has worsened. This can lead to more severe health problems and higher healthcare costs.

The dominance of private healthcare also raises concerns about value for money, and it leaves those who cannot afford it without access to care. The prevalence of private care impacts both accessibility and affordability, which are key determinants of healthcare uptake. While many people prefer private care over public healthcare because it better meets their needs, the quality of private care is often directly proportional to its cost. As a result, private care is primarily available in areas with potential clients.

According to the ‘Somaliland and Demographic Survey 2020’, a majority of women cited financial constraints as the primary barrier to accessing adequate healthcare, with 61% reporting this issue. Additionally, 58% of women identified distance to the health facility as their main obstacle. With the dominance of the private sector, healthcare in Somaliland is more of a business and business owners provide their services where they can make a profit. Consequently, populations in rural areas lack access not only to hospitals and pharmacies but even to basic painkillers needed to manage minor health issues.

Dr. Aadan Haibe, a Health Specialist and a Medical Doctor, has shared his thoughts on the effects of health privatisation on healthcare services in Somaliland. According to Dr. Aadan, privatisation has both positive and negative effects on the accessibility and affordability of healthcare services. On the positive side, privatisation has brought healthcare services closer to where people live, kept practices open for longer hours, and meant healthcare professionals are friendlier to clients – key factors likely to prevent many morbidities and mortalities.

However, on the other side, privatisation has created barriers to healthcare services as only those who have adequate funds can access them. Moreover, the lack of proper supervision and guidance for the staff can make the quality of the services poor. For instance, in some facilities there is no proper storage for medicines and other medical products such as the lab reagents. Additionally, private care does not provide services to emergencies such as car accidents if there is no family member who can immediately cover the costs; thus, all accidents are first referred to public facilities.

Dr. Aadan also shared his thoughts on how privatisation affects healthcare outcomes, particularly for vulnerable populations. He noted private healthcare is almost completely inaccessible to the poor or those who have other vulnerabilities such as those living with HIV. To mitigate any negative impacts of privatisation on healthcare access, Dr. Aadan suggests that better regulation to guide their staffing, accreditation, and licensing, and close supervision of the services must be provided. He emphasized that Somaliland needs both public and private provision of healthcare, but both need to be monitored closely. Both must be provided with support (technically or even financially for those who are providing high-impact services that cannot be bought by the community such as immunisation).

Pharo Foundation’s Health Programmes are making significant strides in addressing the pressing health issues in the region, which are characterized by a struggle for quality, affordable, and accessible healthcare. Dr. Mohamed Aw Ali, the Head of Somaliland’s Health program, stated that the current health programme aims to improve access and utilization of NCD services in the country and targets poor and disadvantaged communities. Furthermore, the NCD centre, currently under construction in Hargeisa Group Hospital, will provide free services to those who cannot afford to pay the visitor’s fee.

Somaliland’s Health Programme was launched in November 2023 with the Prevention and Control of Non-communicable Diseases program and Community-Based Screenings. Since its inception, the program has achieved significant milestones. The program has conducted screenings for diabetes and hypertension, reaching over 1,627 individuals. These screenings play a crucial role in early detection and prevention, and raising awareness is essential for promoting healthier lifestyles and informed decision-making.

Additionally, the program has actively engaged with the community through targeted awareness campaigns about NCDs. These campaigns have reached diverse segments, including university students, lecturers, government workers, and high school students. Moreover, the program has prioritized training community health workers from Mother Child Health Centres, and by equipping these workers to manage a broader range of health situations beyond mother/child care and vaccinations, the program ensures comprehensive care for the entire community.