Solar power is inspiring collective actions to strengthen Somalia's health system for UHC – World Health Organization


Somalia has turned to solar power in rebuilding a health system recovering from a protracted conflict that has taken a significant toll on its public health infrastructures. 
In January 2021, Somalia’s Ministry of Health, supported by the WHO Innovation hub and the WHO Country Office, piloted a solar-powered oxygen delivery system in Hanano General hospital in Galmudug state, working closely with a collaboration of thirteen development, humanitarian, and global health agencies under a Global Action Plan for SDG3 (SDG3-GAP). The collaboration seeks, among other things, to support countries in matching demand with the supply of implementation-ready innovations to accelerate progress toward the health-related goals of the SDG. The collaboration was further enriched by the expertise of the innovator behind the solution, Dr Michael Hawkes, and critical transition-to-scale funding from Grand Challenges Canada.
The outcomes have been remarkable. The solar-powered oxygen system has come to symbolize life for Somalian children in a country where pneumonia accounts for at least one-fifth (15 160) of deaths among children under five years. For example, Abdiaziz Omar Abdi, a two-year-old child in severe distress, was admitted to Hanano hospital in March 2021 with oxygen levels of 60 percent, down from the required minimum level of 90 percent. Doctors immediately put him on oxygen along with ampicillin and dexamethasone medications. Abdiaziz would probably not have survived had he come in sick three months earlier. But three days later, his oxygen level was up to 90 percent, and he was discharged alive and well. “I came because my child was unwell, he was not breathing properly, he was not breastfeeding,” says relieved mother, Zahra. “Now he is breastfeeding. He is feeling well.” Moreover, Abdiaziz received the treatment at no cost. 
Abdiaziz is one of the hundred others who have accessed life-saving oxygen in Hanano hospital to bounce back to life from life-threatening medical conditions such as asphyxia, pneumonia, injuries, trauma, and road traffic accidents. The innovation has also significantly shortened hospital stay, with in-patient hospitalization averaging one day from five days pre-installation.
The value adds from the innovation extends even further. For example, the solar-powered apparatus met electricity needs during frequent power interruptions to maintain the vaccine cold chain and strengthen other aspects of service delivery. An essential consequence is unlocking demand and improving healthcare seeking among catchment communities and populations. “Now, we bring our children to Hanano hospital to live and no longer die,” said Zahra, Abdulaziz’s mother. 
This innovation has brought life back to this hospital; we now have people who come to our hospital from as far as 100 kilometres away”, says Dr Mohamed Abdi, the director of Hanaano hospital. “This is the first time I have seen how one timely investment can save lives. Last year, sadly, more than 180 patients died in the hospital due to a lack of oxygen. Many of them were children. This system will save many lives. If this innovation is used widely in Somalia, it can save the lives of at least 7 000 children who die needlessly from pneumonia”, he added.
Solar oxygen systems have been shown as more cost-effective than other oxygen technologies, requiring minimal maintenance after installation due to their minimal moving parts. They are also easy to use with limited training for health care staff in rural areas. “The system is really easy to use for our healthcare providers and has drastically reduced the logistic and financial burden of always having to fuel our diesel generators”. Such a climate-conscious approach and the positive healthcare demand and supply effects indicate a vast potential to strengthen primary healthcare in off-grid and infrastructurally challenged settings, where most children’s deaths occur. 
Remarkably, Somalia is innovating in other ways. Faced with a relapse of vaccine-preventable diseases from disruptions caused by the COVID-19 crisis, Somalia’s health sector at federal and state government levels worked with partners to experiment with innovative service delivery models to accelerate immunization coverage to vulnerable children with zero dose immunizations. The strategies include a combination of outreaches and mobile and fixed-post immunization models between November 2021 and February 2022.
Past investments from SDG3-GAP partners, particularly GAVI, WHO and UNICEF, in strengthening Somalia’s EPI and building community trust in vaccinations were critical preconditions that enhanced the rapid expansion in immunization capacity using the innovative service delivery approaches. From the existing immunization points across the country, capacity rapidly expanded to include mobile units, fixed posts, schools and even stadiums. Within two months, the campaign had covered the 54 districts in Somalia (and Somaliland) that had the lowest immunization coverage, the highest number of zero-dose children and districts that had reported outbreaks of vaccine-preventable diseases. Overall, the accelerated campaign reached 75 217 children with zero-dose immunization, 104 000 children vaccinated for measles, 82 000 vaccinated for polio, and 954 400 doses of COVID-19 vaccine. The lessons learned from the accelerated immunization campaign are informing a revision of Somalia’s expanded immunization program and strengthening primary health care.
The solar-powered oxygen delivery and service delivery innovations for immunization are a few examples of Somalia’s approach to transforming its health system, and early successes have prompted increased calls to take such innovations to scale. But scaling such transformational products and services quickly enough would require extensive stakeholder alignment, which is traditionally challenging, given current locally and globally dispersed stakeholder networks. 
The SDG3-GAP partners are using an “Innovation Scaling Framework”, developed by the WHO Innovation Hub, to catalyze the scaling up and sustainability of effective health innovations to bridge this gap. The approach involves bringing together governments, partners, and innovation “aggregators” to identify and build supply pipelines for evidence-based, scaling-ready innovations that are already happening and showing impact. One example of this effort is the roundtable discussion on “Bridging oxygen access gaps in Somalia: towards building a resilient health system in fragile context”, organized by WHO in March 2022. Following the recommendations of the policy dialogue, SDG3-GAP partners conducted a joint assessment of the oxygen ecosystem at the primary health facility level in Somalia, which will inform the ongoing development of a road map and pooled funding mechanism for further scale-up at the primary health care level.
The approach is already yielding results. For example, following the pilot in Hanano, the solar-powered oxygen system was scaled to four more hospitals located in Kismayo, Baidoa, Hudur Hospital, and Dhusamareb, with funding from the governments of Canada (via the ACT Accelerator) and the Italian government. On the eve of World Health Day 2022, the WHO Somalia country office commenced scaling up solar installation to provide electricity to 100 PHC centres, enabling optimal functioning and solving chronic power problems in a climate-friendly way. In addition, three Pressure Swing Adsorption (PSA) oxygen plants have been established, and another process is underway to jointly procure and distribute 200 portable oxygen concentrators across the country. 
WHO’s global health leadership and the trusting relationships between the SDG-GAP partners and the Government of Somalia, including the UN Resident and Humanitarian Coordinator in Somalia, have been very crucial to these efforts. In addition, SDG-GAP partners are actively engaged in opening more pathways and funding mechanisms to move this innovation to scale. 
SDG3-GAP partners recognize that innovation must address needs and be accessible to the people who have those needs. To connect innovations with people who need them, SDG3-GAP partners are collaborating to deliver services more effectively and break through barriers to equitable access to health services. Partners working across humanitarian, development and peace-building efforts have adopted a nexus approach and agreed on a set of collective outcomes toward a more coherent, collaborative planning and implementation of such efforts. A notable outcome of this increased in-country collaboration is supporting the Government of Somalia to revise the Essential Package of Health Services (EPHS 2020), drawing on lessons learnt from the gaps in implementing earlier EPHS versions (EPHS 2009). In addition, they have jointly developed an implementation guideline and set up a coordination body for EPHS 2020 implementation. To provide further impetus, the World Bank is funding the Damal Caafimaad Project (2021-2026), which aims to improve the coverage of EPHS 2020 in select geographic areas while strengthening the stewardship capacity of Ministries of Health to coordinate and implement mid and long-term health system strengthening strategies. The project demonstrates vital elements of the nexus approach in taking a step from the humanitarian emergency approach to providing essential public services while strengthening governmental systems. WHO is also setting up a ‘Transition To Scale’ funding mechanism to enable countries to identify, test, and localize innovations into government programmes to sustain scale up products or service delivery innovations.
The early and ongoing gains recorded to align and scale innovation varieties in Somalia are promising signs for its progress towards healthy lives and well-being for all. In addition, SDG3-GAP collaborations have emerged as critical to connecting innovations to the population that needs them, using EPHS as a vehicle. As they become established and institutionalized, such joined-up efforts increase optimism about Somalia’s progress towards healthy lives and well-being for all.
 
Solar Powered Oxygen Concentrator System, Hanaano Hospital. Dhushamareb, Galmudug.
Solar Powered Oxygen Concentrator System, Hanaano Hospital. Dhushamareb, Galmudug, Somalia.
©WHO/Somalia Country Office.

 
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