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Abstract

  1. Top of page
  2. Abstract
  3. The Role of State Capacity for the Provision of Governance Services
  4. Why Do Task Properties Matter?
  5. Somalia—Service Provision in a Collapsed State?
  6. Effective Provision of Malaria Prevention Services
  7. Effective Provision of Tuberculosis Services
  8. The HIV/AIDS Project—The Challenge of Complex Service Provision
  9. Conclusion
  10. References

Concentrating on the health sector, this article argues that the provision of collective goods through external actors depends on the level of state capacity and the complexity of the service that external actors intend to provide. It shows that external actors can contribute most effectively to collective good provision when the service is simple, and that simple services can even be provided under conditions of failed statehood. Effectively delivering complex services requires greater levels of state capacity. The article also indicates that legitimacy is a key factor to explain variance in health service delivery. To demonstrate this, the article assesses health projects in Somalia. It shows that simple services—malaria prevention and tuberculosis control—are provided effectively in all three Somali regions, including the war-torn South-Central region. In contrast, the HIV/AIDS project only achieved substantial results in Somaliland, the only region with a comparatively higher level of state capacity, and failed in the South-Central region and Puntland.

External and nonstate actors play a key role when it comes to the provision of governance services in areas of limited statehood. While effective territorial control and state capacities are often regarded as critical preconditions for the provision of governance services through external actors (Rotberg 2004), weak states often lack the ability to exercise effective political control and to enforce political decisions within the borders of their own polity. One key question is thus whether and to what external and nonstate actors can effectively provide collective goods if the state is largely or even completely absent.

Concentrating on the health sector, this analysis assesses the impact of statehood on the delivery of governance services, with a focus on the role of task properties. Its key argument is that the successful provision of collective goods through external actors depends on the level of state capacity and the complexity of the service that external actors intend to provide. External actors can contribute most effectively to collective good provision when their task is simple, and their efforts can be successful even if the state is largely or completely absent. Effectively delivering complex services requires greater levels of state capacity or institutionalization. In addition, the article provides evidence that legitimacy is critical for service delivery in the sense that external actors can only be successful when they are accepted by local authorities and their activities are perceived as legitimate (see Krasner and Risse 2014).

The article focuses on projects of the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) in Somalia. The Global Fund is a transnational public–private partnership that was launched in 2002 as a result of the growing recognition that the international community responded too slowly to effectively fight HIV/AIDS, tuberculosis (TB), and malaria. As a partnership representing governments, civil society, the private sector, and affected communities, it operates without any country presence—instead, it leverages the capacity of international actors and local stakeholders in the design and implementation of its projects.

While Somalia represents an extreme case of state failure, there is an important subregional variance in terms of state capacity and domestic control within the country. Somalis, aid workers, and others have mentally divided the country into three, referring to it as the separate units of South-Central, Puntland, and Somaliland. The situation is most severe in South-Central Somalia, which is characterized by armed conflict and lawlessness. Although Puntland is more stable than South Central, many of the same challenges to providing governance services also apply here. An exception in terms of statehood is the unrecognized Republic of Somaliland, where a functioning regional government maintains public order (Harper 2012).

Case studies are used to show that state capacity and the complexity of the task are important determinants for the outcomes of the service delivery efforts of external actors. The article differentiates between simple and complex service delivery tasks: Malaria prevention through insecticide-treated bed nets is a simple task. Distributing nets requires only few discrete actions by a single actor. Though more complex than distributing bed nets, the provision of TB services is still relatively simple. Providing HIV/AIDS services, in contrast, is a complex task that requires substantial capacity and cooperation between multiple actors.

The case studies show that the Global Fund's malaria and TB projects are successful in all Somali regions, supporting the argument of this special issue that simple services can be successfully provided by external actors even under conditions of failed statehood (Krasner and Risse 2014). In this context, the TB case points to the important role of local legitimacy in the provision of services. Local acceptance of helped to create a protective environment for project implementers, compensating for the lack of statehood. However, while the TB project did not collapse, it was negatively affected by the deteriorating security situation.

In contrast, the Global Fund's HIV/AIDS project achieved only significant results in Somaliland. Insecurity and scarce health capacities hindered an effective implementation in Central-Somalia and Puntland, demonstrating the difficulties that complex health projects can face when the state is largely absent. Due to cultural and religious beliefs, the provision of HIV/AIDS services was not regarded as legitimate by local actors, and this lack of legitimacy obstructed an effective project implementation. The local support that can substitute for the lack of statehood was missing.

To assess the effectiveness of Global Fund projects, the distinction between outputs, outcomes, and impacts is used (Global Fund 2007). Outputs represent the first dimension for assessing the effectiveness of an institution. Distributing insecticide-treated bed nets to developing countries could be an important output of a global health project that intends to provide malaria services. Outcomes go a step further and relate to the effects that occur as a result of the project outputs, say, the proportion of people in malaria-endemic areas who sleep under supplied bed nets.

Impact refers to problem solving in the most demanding sense. Health partnerships that reduce the number of new malaria cases or deaths have successfully made an impact. Researchers usually focus on outputs and outcomes, as it is methodologically difficult to demonstrate a clear causal link between the activities of institutions and the solving of a particular problem (Young 1999). As the available data for Somalia do not allow making any strong statements about impacts, I also mostly focus on outputs and outcomes rather than impact.

Data for the case studies were collected on research trips to Kenya's capital Nairobi.1 Since the early 1990s, aid operations for Somalia have been managed from Nairobi, due to the chronic instability in Somalia. Interviews were conducted with actors that were involved in the projects (e.g., project managers, implementing NGOs) and informed stakeholders without any participation in the projects to receive an external view on the project results.

The Role of State Capacity for the Provision of Governance Services

  1. Top of page
  2. Abstract
  3. The Role of State Capacity for the Provision of Governance Services
  4. Why Do Task Properties Matter?
  5. Somalia—Service Provision in a Collapsed State?
  6. Effective Provision of Malaria Prevention Services
  7. Effective Provision of Tuberculosis Services
  8. The HIV/AIDS Project—The Challenge of Complex Service Provision
  9. Conclusion
  10. References

Several literature streams perceive the state's ability to exercise effective territorial control, and its capacity to set and enforce policies and political decisions as critical conditions for the provision of governance services. The literature on state failure in particular emphasizes the role of the monopoly of force and state-produced security as a central precondition for an effective provision of governance services in other areas, such as health, nutrition, and education. A state that holds the monopoly of violence over a given population and that has the ability to supply a minimum of security is a necessary condition before other collective goods can be provided (Fukuyama 2004; Rotberg 2004).

There is also a literature on the delivery of health services in conflict settings that demonstrates why service provision in the health sector is sensitive to security. Generally, studies argue that more insecurity means less access to health services and greater risk to those seeking to provide services (Toole, Waldman, and Zwi 2006; Waldman 2008). In conflict settings, patients can be deterred from seeking health care and health workers may have difficulties attaining health facilities. Lack of security can also impede progress in the reconstruction of health facilities, slow outreach campaigns, restrict delivery of needed supplies to health care facilities, and affect the labor force if healthcare providers are intimidated. Civil wars also destroy the health infrastructure, diminish the human capital, and displace large populations—bad food, contaminated water, poor sanitation, and inadequate shelter transform refugee camps into vectors for infectious disease, which can easily spread to wider populations (Human Security Report Project 2010).

In addition to the provision of security, the state's ability to effectively formulate and implement political decisions is considered to be critical for the successful provision of governance services. There is, for example, evidence that the effectiveness of international programs for improving access to malaria treatment depend on the ability of the state to regulate the private sector. Without effectively banning old and ineffective antimalarials from the country, people will seek to treat fevers with ineffective and counterfeit drugs from private pharmacies (Yamey, Schäferhoff, and Montagu 2012). Other publications from the field of global public health indicate that limited administrative capacity at ministerial or district level, and weak public health systems undermine the ability of international actors to achieve health results (Garrett 2007).

Why Do Task Properties Matter?

  1. Top of page
  2. Abstract
  3. The Role of State Capacity for the Provision of Governance Services
  4. Why Do Task Properties Matter?
  5. Somalia—Service Provision in a Collapsed State?
  6. Effective Provision of Malaria Prevention Services
  7. Effective Provision of Tuberculosis Services
  8. The HIV/AIDS Project—The Challenge of Complex Service Provision
  9. Conclusion
  10. References

One central argument of this article is that external actors can contribute most effectively to service provision when their task is simple. Task complexity can be operationalized along two dimensions (Krasner and Risse 2014): the number of organizations or entities that must be coordinated, and the number of interventions that must be undertaken to successfully deliver a service. Based on these distinctions, this article differentiates between low and high task complexity.

Low Task Complexity: Malaria Prevention and Tuberculosis Services

The main tool for malaria prevention is the provision of insecticide-treated bed nets. These nets incorporate insecticides directly into net fibers, and are thus a key prevention tool to protect against malaria. Why is it simple to increase the access to bed nets? The reason is that the distribution of bed nets is often provided through mass distribution campaigns. Even in the most challenging circumstances, it is likely that windows of opportunities can be found to deliver them. Only limited capacity and skill are required to distribute them. Bed net provision is thus similar to immunization—only few actions by one actor are needed to provide the net.

Though more complex than distributing bed nets, the provision of TB services is still relatively simple. TB is a medical problem and does not require the involvement of multiple sectors and actors.Furthermore, the recommended treatment protocol for TB requires the supervision of a patient's treatment by an observer to ensure that the patient takes the treatment regularly, usually over a six-month period. However, depending on the local conditions, supervision takes place at a health facility, in the workplace, in the community, or at home. Interactions between the service provider and the patient can be minimized if required by the local situation (Hehenkamp and Hargreaves 2003). Neither TB diagnosis nor treatment necessarily requires highly skilled medical personnel. These services can be provided by auxiliary health workers and community health workers.

High Task Complexity: HIV/AIDS Services

The fight against HIV/AIDS represents a complex problem for many reasons. Fighting HIV/AIDS needs engagement from multiple organizations and sectors, such as health, nutrition, education, and labor. HIV/AIDS is also complex from a purely medical perspective. It is a complicated drug regime and many patients need close medical supervision. Administering antiretroviral drugs (ARVs) requires skilled health workers. The timely administration of ARVs to pregnant women with HIV/AIDS and their newborns can also prevent mother-to-child transmission, but providing these services requires skilled health workers and a strong public health infrastructure. Projects also involve diagnosing and treating sexually transmitted infections (STIs), as people infected with STIs are up to 10 times more likely to acquire HIV, and are also more likely to transmit it through sexual contact than other HIV-infected persons. In addition, preventing the spread of HV/AIDS requires population-wide behavior change, but projects that aim at changing social norms are complex in their design and implementation.

Somalia—Service Provision in a Collapsed State?

  1. Top of page
  2. Abstract
  3. The Role of State Capacity for the Provision of Governance Services
  4. Why Do Task Properties Matter?
  5. Somalia—Service Provision in a Collapsed State?
  6. Effective Provision of Malaria Prevention Services
  7. Effective Provision of Tuberculosis Services
  8. The HIV/AIDS Project—The Challenge of Complex Service Provision
  9. Conclusion
  10. References

Somalia has been without a functioning central government since 1991, when Siad Barre's military regime collapsed and civil war among clan militias broke out. In 2004, the Transitional Federal Government (TFG) was created in South-Central Somalia. Although backed by the United Nations, the TGF's ability to exercise effective territorial control remained limited to Somalia's capital, Mogadishu.2

In 2006, the TFG was challenged by the sudden rise of the Islamic Courts Union (ICU), which soon controlled large parts of South-Central Somalia. In late 2006, an alliance of U.S.-backed warlords and Ethiopian troops recaptured parts of the Southern territory (Menkhaus 2009). However, the former military arm of the ICU, the Al-Shabaab, continued the war against the TFG. Military clashes between the al-Shabaab militia and supporters of the TGF are commonplace, with al-Shabaab and other radical Islamic groups controlling large parts of South-Central Somalia. Today, Somalia still tops the lists of the Failed States Index (Fund for Peace 2012).

There is an important subregional variance in terms of statehood, as the country is divided into the three separate units of South-Central, Puntland, and Somaliland. South-Central Somalia is a war-torn stateless area that suffers seriously from the protracted civil unrest and a devastating humanitarian situation. South-Central is in territorial terms the largest part of Somalia, and, with an estimated 6 million inhabitants (out of a total population of 11.5 million), it is also the part with the largest population. A similar situation can be found in the regional state of Puntland, where 2.4 million Somalis live. While Puntland remains more stable than South-Central, the regional authorities lack almost any capacities and are hardly able to provide basic law and order in the region.

An exception in terms of statehood is the to date unrecognized Republic of Somaliland in the North-Western corner of Somalia, where a functioning regional government is able to maintain public order. The de facto regime in Somaliland enforces stability and security through over 17,000 police and security forces. Somaliland also has its own administration, and, in contrast to the two other regions, a health infrastructure that provides a modest level of services to its citizens (Harper 2012).

The existence of three regional Somali authorities and the persistent instability also affect the organization of service delivery. In the absence of a functioning Somali government, bilateral donors and international organizations created the Somalia Aid Coordination Body in 1994 to coordinate their aid activities in Somalia. As a result of the instability in Somalia, this coordination body was founded outside of Somalia, in Kenya's capital, Nairobi. Since 2008, this institution has been called Coordination of International Support to Somalia (CISS). The Global Fund recognized the CISS's Health Sector Committee (HSC) as eligible to submit project applications. Although the HSC is an essential decision-making body in the development and monitoring of Global Fund projects, the Somali authorities are not represented in it to avoid political conflicts between the different Somalia authorities.

Effective Provision of Malaria Prevention Services

  1. Top of page
  2. Abstract
  3. The Role of State Capacity for the Provision of Governance Services
  4. Why Do Task Properties Matter?
  5. Somalia—Service Provision in a Collapsed State?
  6. Effective Provision of Malaria Prevention Services
  7. Effective Provision of Tuberculosis Services
  8. The HIV/AIDS Project—The Challenge of Complex Service Provision
  9. Conclusion
  10. References

The Global Fund's malaria project started in Somalia in 2004, with UNICEF as PR and a budget of US$12.8 million. A second project was launched in 2007 (US$24.8 million). The key goals of these projects were to significantly reduce malaria deaths, particularly in children under 5; to reduce malaria in pregnancy; and to contribute to building a national health system. Malaria is a major health problem in all three Somali regions. For 2007, the World Malaria Report (World Health Organization 2009b) estimated that there were 608,831 cases of uncomplicated malaria and 3,491 malaria deaths in Somalia.

The main tool for malaria prevention is the provision of malaria-preventing bed nets, either insecticide-treated nets (ITNs), or long-lasting insecticidal nets (LLINs). The distribution of bed nets is the one of the major successes of the Global Fund's Somali projects. Before the Global Fund's malaria project was introduced to the country in 2004, only few households possessed a bed net. A survey conducted in 2004 estimated that about 10% of households own a bed net, although more than 50% of the respondents were aware that nets are a method for preventing malaria. Through the Global Fund, bed nets are now widely distributed in all parts of Somalia, including the South-Central.

A rapid distribution of bed nets was initially hampered by the global production of nets. In 2005, the global demand for nets outstripped supply, which resulted in much longer procurement times than originally anticipated. After this initial challenge, LLIN coverage was quickly scaled up through mass campaigns. By mid-2006, over 200,000 LLINs were distributed to health facilities and vulnerable groups that were displaced due to conflict. Through mass campaigns—LLIN distribution was piggybacked onto immunization campaigns—the project managed to provide over 700,000 LLINs by the end of 2010 (Global Fund 2012a, 2012b). This resulted in substantial increases in coverage. Most of the Somali districts have coverage rates of 70% or more, including the districts in South-Central Somalia (Figure 1).3

figure

Figure 1. Coverage with Long-Lasting Insecticide Treated Nets in Eight Regions of South-Central Somalia

Source: Roll Back Malaria (2010).

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In 2011, another 360,000 LLINs were distributed to more than 140,000 households in regions of Hiran, Lower and Middle Shabelles, and Lower and Middle Jubas in South-Central Somalia, targeting people living in the most high-risk areas. Overall, more than 950,000 nets have been distributed in Somalia through the Global Fund (Global Fund 2011). The project partners also conducted campaigns to educate families about how to prevent getting malaria and where to seek care if someone contracts the disease.

While Global Fund's grant performance reports mention the unpredictable security situation, particularly in the South, the distribution of LLINs was possible due to campaign-style mass distributions carried out by NGOs. The project efficiency, however, suffered from the insecurity. The project costs increased due to higher transportation cost as the pirate activities near the Somali coast has made a significant impact on the shipping cost for commodities. The nets were then shipped to Mombasa and transported by road inside of the country, and this is expensive because agencies are required to hire cars and armed guards from the local clan as a condition for operational presence. Cost of transport to Southern areas quadrupled.

Effective Provision of Tuberculosis Services

  1. Top of page
  2. Abstract
  3. The Role of State Capacity for the Provision of Governance Services
  4. Why Do Task Properties Matter?
  5. Somalia—Service Provision in a Collapsed State?
  6. Effective Provision of Malaria Prevention Services
  7. Effective Provision of Tuberculosis Services
  8. The HIV/AIDS Project—The Challenge of Complex Service Provision
  9. Conclusion
  10. References

Somalia is one of the countries with the largest burden of TB worldwide. A survey conducted by the WHO estimated that 9,500 new smear-positive TB cases occur in the country in each year (Munim 2006). With a TB mortality of 67 per 100,000 in 2003, TB also constituted one of the leading causes of death in Somalia. Following the approval of the CISS's funding request to the Global Fund in 2003, World Vision International was officially announced as the project's PR. A second project started in 2008.4

World Vision is responsible for the overall planning, financial and project management, and reporting to the Fund Portfolio Manager in Geneva. It manages the drug procurement, and runs several TB centers in Somalia. Together with WHO, and the Italian NGO Comitato Collaborazione Medica (CCM Italy), World Vision monitors the project performance, including on-site monitoring in Somalia to assess the results of the TB centers. The NGO also collaborates with the three regional authorities in Somaliland, Puntland, and South-Central Somalia to ensure access to the regions. Together with CCM Italy, World Vision provides training in preventing, diagnosing, and treating TB to health workers. The first TB project included 11 international and local NGOs that run hospitals and health centers in the three Somali regions. WHO also plays a key role for the TB project, especially for logistics, health worker training, and monitoring and evaluation (M&E).

Despite the persistent civil war in Somalia, the TB project achieved remarkable results in the three Somali regions. Three outcome indicators are used to assess the effectiveness of TB projects: the treatment success rate, case notifications, and the case detection rate. The treatment success rate measures the percentage of detected TB cases successfully cured. A high treatment success rate shows that the quality of services is good. While WHO has set a global target of 85% treatment success by 2015, the national estimate for treatment success in Somalia is as high as 86% (World Health Organization 2011). In Somaliland, treatment success is even slightly higher, with over 90% of TB patients successfully cured.

The second indicator—case notifications—relates to the identification of patients. Due to a lack of health infrastructure in developing countries, TB patients are often not identified as such. A key component of TB projects is thus to identify people suffering from TB so they can be treated. In terms of identifying new cases, the Global Fund's TB project proved to be successful. Between 2003 and 2005, the number of registered TB patients increased from 9,200 to over 13,000. This represents an increase of 40.2%. From a public health perspective, “smear-positive” cases are the most important because they are most infectious. The number of identified sputum-positive cases increased from 5,190 in 2003 to 7,163 in 2005, an increase of 38% (Figure 2). As discussed below, the number of notified cases slightly decreased as a result of the increased inaccessibility of parts of Puntland and South-Central in 2006 and 2007.

figure

Figure 2. Case Notifications in Somalia (2002–2007)

Source: Author's calculation based on data provided by World Vision International.

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The third success indicator is the case detection rate that can be calculated based on the number of the notified cases and the estimated TB incidence in a country. The case detection is the percentage of all registered TB cases out of the total estimated TB cases in a country in a specified period, usually a year. The global target for TB case detection is 70%, as set by WHO's Stop TB Partnership. According to WHO estimates, the TB case detection rate in Somalia was at 42% in 2002. Based on the number of registered cases, a WHO survey estimated the national case detection rate of Somalia at 74% in 2006. For Somaliland and the South-Central zone, the case detection rate was estimated at 75%; for Puntland, it was estimated at 70% (Munim 2006). However, the case detection rate for Somalia is difficult to measure because it is a function of the population size. As population figures for Somalia can only be considered rough estimates, the number of registered cases is a more reliable indicator to measure the effectiveness of project.

Development a Disease-Specific Infrastructure for the Provision of TB Services

One key factor for the effectiveness of the TB project is that a disease-specific health infrastructure existed in the country when the Global Fund project started. Rather than building the health infrastructure from scratch, the project could build upon and expand an existing infrastructure for the provision of TB services. After the end of the military regime in 1991, WHO, with assistance of international and local NGOs, began to establish a TB project in Somalia in 1995, introducing Directly Observed Therapy, Short-course (DOTS), the recommended TB control strategy. According to WHO guidelines, it is required that TB patients receive their treatment regularly throughout a six-month period to be cured. In a nomadic country like Somalia, where an estimated 60% of the population are (semi)-nomadic pastoralists, it is challenging to ensure that TB patients take their treatment regularly and completely. The provision of treatment to a nomadic population requires establishing a network of TB centers to ensure that the population has access to a health facility with a trained health worker who is able to diagnose and treat TB.

The WHO project established an initial health system infrastructure for the provision of TB services in Somalia. In 2000, all 18 regions in Somalia had at least one TB center. By 2004, the year the Global Fund launched its TB project, WHO had established a network of 30 TB centers in Somalia. Health workers with the skills to diagnose and treat TB were available, with many of these being auxiliary community health workers. A rudimentary TB drug supply system was also in place. This system improved substantially when the Global Fund project began to operate; while drug supplies for many districts were erratic until the project began, the availability of TB drugs has improved substantially since 2004.5

Building on the WHO project, the Global Fund's TB project has been yielding remarkable results despite the challenging environment within which the project operates. One key factor for this achievement was the enhanced access to diagnosis, treatment, and cure for TB patients. Through the Global Fund project, the number of health facilities providing TB services increased from 35 to 49 between 2004 and 2007. In addition, 18 of the existing TB centers were rehabilitated over this time frame. Additional health workers were trained to ensure that each TB center has at minimum one trained staff member. In 2010, a total of 63 TB centers existed in Somalia. Through the network, it was possible to reach an increased number of patients, including those who live in rural and conflict-affected areas. The dense TB network encouraged compliance with the DOTS regimen by minimizing the distances that had to be travelled by patients attending clinics and by outreach workers searching for defaulters.

One other factor considered important for the effectiveness of the TB project is the monitoring and evaluation (M&E) component. A rudimentary reporting system for TB was already in place in 2004. Health workers reported about the detection and treatment of TB cases to WHO. Building on this system, World Vision, together with CCM Italy and six Somali staff members, monitors the progress and the quality of services at the service delivery points. The inclusion of local Somali staff has been described as critical, particularly because they can reach areas where international staff has no access. They can ensure that the TB data are reliable and that health workers receive training and the needed supplies.

Dealing with Persistent Insecurity

A key question is how the TB project managed to deal with the insecurity in Somalia, particularly in South-Central. One first finding is that between 2002 and 2007, the majority of violent events were geographically concentrated. The EDCAS project shows that a substantial number of violent events took place in the Mogadishu area, and in the Kismayo and Baioda regions (Chojnacki, Grömping, and Spieß 2009, 23). Although other areas in South-Central and Puntland also suffered from armed conflict, the violence is often localized and short-lived. Under these circumstances, health workers and patients may temporarily loose access to health facilities, but after the fighting stops, the provision of services becomes possible again.

The international NGOs also launched the Safety Preparedness and Support Project (SPAS) that provides targeted security support services. The overall objective of SPAS is to reduce the risks posed to aid workers operating in Somalia. NGOs operating in Somalia report security incidents to the SPAS office in Nairobi, which rapidly disseminates this information to other NGOs and aid agencies. If certain regions are considered to be too insecure and unstable, SPAS warns all NGOs against accessing these areas. This system appears to work well.

However, World Vision staff also argue that the insecurity can cause challenges in supplying the health centers with drugs and health commodities. Armed conflict and roadblocks by militias can prevent the transport of drug supplies, and this increases the risk of drug stock outs. Due to this risk, health centers in conflict zones receive extra supplies to establish drug buffers. While there is considerable resistance within the development aid community to the notion of armed protection, in Somalia, aid agencies have no choice but have to pay for armed protection to run their operations. In Puntland and the South-Central Somalia, armed guards and escorts are omnipresent, and using them is the only possible way in which work can continue. Providing “security” is a major source of income for clans and militias, so transporting medical supplies via trucks from Somaliland to the Central-South cause substantial costs because many clan borders need to be crossed.

The Role of Local Acceptance and of Alternative Forms of Authority

There are two factors that also contributed to the successful implementation of TB project despite the chronic instability: the support from local communities, and the existence of alternative forms of authority.

First, within the aid community, the concept of acceptance—cultivating relations with local actors and communities—is increasingly recognized as an appropriate and effective approach to providing services in insecure settings (Stoddard and Harmer 2005). The acceptance and support of local actors (e.g. clan chiefs, religious leaders), and the recognition by local leaders that TB is a major problem in their communities, were key success factors of the TB project. Project managers reported that without local support, running effective aid projects in Somalia would be impossible. The project manager from Mercy USA, an American NGO that runs a TB center in Mogadishu, emphasized that “the acceptance of the local people is crucial. Without the acceptance of the local actors, a project cannot be effective.”6 NGO officials emphasized that it takes time to gain the acceptance of local actors, but once local actors perceive the provided services as a needed “good” for their communities, projects can be effective, even under such unstable conditions as in Mogadishu. It was thus critical that several international NGOs remained in Somalia during the 1990s.

Second, while Somaliland and Puntland formed their own administrations, providing a degree of stability, localized forms of law and order were also emerging in South-Central. In the absence of any effective central government, the authority of sharia courts had been growing since the late 1990s, filling a vacuum. At the outset, the courts only represented a loosely defined group of independent, discrete units, each one taking responsibility for establishing a degree of order within its limited area of influence in Mogadishu and surrounding areas. Over the years, the authority of the courts began to grow, and was often welcomed by a population weary of warlords and banditry. The most significant contribution of the courts ensured was the provision of basic law and order. And although the courts executed bloody sharia punishments, they were increasingly viewed as legitimate authorities. The sharia courts gained support because they provided basic services to a neglected population, starting to perform key functions of government in a stateless society (Harper 2012). In 2006, the courts came together to form the UIC. Key informants reported that while the courts were in power, the situation in South-Central was safer than it had been for many years. There was at least a degree of law and order after years of violent chaos, making it easier for external actors to operate. The UIC was driven out after only six months in power by U.S.-backed Ethiopian troops. This international intervention led to the emergence of Al-Shabaab, a far more radical group compared to the UIC, and an explosion of violence in the South-Central region. The breakdown of the basic system of law and order had a negative impact on the results of the TB project.

Impact of the Deteriorating Security Situation

Due to the armed conflicts between the Al-Shaabab and the forces that supported the TGF, the number of violent events increased in South-Central (Figure 2). The violence in South-Central also led to a large number of internally displaced people. While Puntland was perceived as stable until the end of 2006, it turned into an unstable and insecure place, with continuing violent incidents, including armed clashes and assassinations, and frequent bombings. Especially for international aid workers, the insecurity has increased in Puntland. Organized crime networks, which kidnap and attack aid workers, have made a no-go area out of Puntland, and the number of attacks against aid workers increased substantially since 2006 (Stoddard, Harmer, and DiDomenico 2009).

While the effectiveness of the TB project remained high, the number of notified cases slightly decreased as a result of the increased inaccessibility of parts of South-Central and Puntland in 2007. The identification of TB cases through targeted outreach activities became more challenging because of the fighting. Figure 2 shows how the worsened security situation impacted on the detection of new TB patients. It shows a substantial increase in the number of violent events and conflict-related fatalities in 2007, and a decreasing number of detected TB patients: The number of smear-positive TB cases fell from 7,100 to 6,150, the number of violent events increased from 73 to 407, and the number of fatalities increased from 493 to 2,182 (Figure 3). World Vision's staff supported the assumption that the decrease in case notifications is linked to the intensification of the conflict.7

figure

Figure 3. Impact of Security Situation on Tuberculosis Case Notifications, 2004–2007

Source for case notifications: Author's calculation based on World Vision data. Source for violent events: Chojnacki et al. (2009).

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The security situation also impacted on the M&E project and the procurement system. The ability of CCM Italy to travel in Somalia to monitor the state of the project severely decreased after 2006. An increasing number of TB centers can only be monitored and accessed by the national Somali staff that works with World Vision and CCM Italy. However, a number of activities had to be postponed because of the conflict. It was planned to further scale up the number of TB centers but this turned out to be impossible because of the intensifying civil war.

The HIV/AIDS Project—The Challenge of Complex Service Provision

  1. Top of page
  2. Abstract
  3. The Role of State Capacity for the Provision of Governance Services
  4. Why Do Task Properties Matter?
  5. Somalia—Service Provision in a Collapsed State?
  6. Effective Provision of Malaria Prevention Services
  7. Effective Provision of Tuberculosis Services
  8. The HIV/AIDS Project—The Challenge of Complex Service Provision
  9. Conclusion
  10. References

Compared to HIV prevalence rates in other sub-Saharan Africa countries, Somalia has a relatively low but increasing prevalence rate. While the national prevalence rate is estimated at 1.0%, it reaches higher rates in urban centers and refugee camps; for example, prevalence is estimated at 2.7% in Berbera, at 1.6% in Bossaso, and at 2.2% in the Daami IDP camp. UNAIDS estimated that over 23,000 people live with HIV/AIDS in Somalia, and that at least 6,000 people are in need of antiretroviral treatment. In 2007, 1,400 people died of HIV/AIDS (UNAIDS 2008, 6).

Cultural and religious beliefs strongly influence the provision of HIV/AIDS services in Somalia. Discussion of sexual and reproductive health (SRH) issues is a taboo, leading to significant knowledge gaps about SRH. Low levels of education and literacy, especially among women and the large rural population, combined with harmful traditional practices (94% of women have undergone female genital cutting) further exacerbate the problem. There is a strong HIV/AIDS stigma in Somalia, and discrimination of HIV-infected people is common, with frequent reports of violence against people living with HIV/AIDS (UNAIDS 2008, 6).

The HIV/AIDS project in Somalia was launched in 2005 to control the spread of HIV through effective prevention strategies, and to provide antiretroviral treatment and care to people living with HIV/AIDS. A second project started in 2010 (Global Fund 2012c).8 Planned intervention areas included educational campaigns, diagnosis and treatment of STIs, condom distribution, the prevention of mother-to-child transmission, and the provision of antiretroviral treatment. It was also planned to improve the health system, especially through the second project, and to create effective structures for coordinating the HIV/AIDS response. UNICEF took over the role of the Principal Recipient. Since the UNICEF office was closed in 1994 because of the persistent violence in Mogadishu, the UN agency coordinates its projects from Nairobi. Similar to the TB project, the HIV/AIDS project relies mainly on international and local NGOs for the implementation of activities.

Effectiveness of the HIV/AIDS Project

On a national level, the Somali HIV/AIDS project only achieved limited results. It achieved tangible results in Somaliland, but failed in Puntland and South-Central Somalia. Measured by the ambitious targets proposed in the grant proposal, the performance of the HIV/AIDS project was weak. By the end of 2007, more than two years after the project's launch, only 323 people received antiretroviral drugs (cumulative number), and 153 HIV/AIDS orphans were supported. In addition, a total of 775,000 condoms were distributed (UNAIDS 2008). By October 2008, additional progress was marginal, as implementation activities remained limited in 2008.9

By 2009, the project aimed to distribute 25 million condoms, to train 5,400 health workers in the diagnosis and treatment of sexually transmitted infections in 90% of Somali districts, to treat 45,000 STI cases, to create in each region an integrated project for antiretroviral treatment, to provide antiretroviral treatment to 1,000 people living with AIDS, to give 200–300 pregnant women access to services for the prevention of mother-to-child transmissions, and to support 360 AIDS orphans. However, by the end of 2009, only 2,178 (out of an estimated 23,480 people infected with HIV/AIDS) were detected through voluntary counseling and testing. Coverage with antiretroviral treatment remained at very low levels: In total, 742 have ever been enrolled in treatment in Somalia, of whom 578 still received the treatment in 2009. This compares to 5,000 people in need of treatment (Figure 4). According to the latest Global Fund data, over 800 people received treatment in 2010 (Global Fund 2012c).

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Figure 4. Unmet Need for Antiretroviral Treatment in Somalia

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Implementation of the HIV/AIDS Project in Somaliland

In Somaliland, the HIV/AIDS project achieved tangible programmatic results with respect to both, the prevention and treatment of HIV/AIDS. To prevent the spread of HIV, media campaigns were implemented through radio and print media to educate the Somali population about the different ways of HIV transmission. Community awareness campaigns were conducted to convince religious leaders and clan elders to become engaged in the fight against HIV/AIDS (UNAIDS 2010, 22). Including religious and local leaders in HIV/AIDS education campaigns is critical to create a basic knowledge among the population about the spread of the virus and also for the reduction of stigma. Building on the stable security situation in Somaliland, international staff was able to educate the Somalis about HIV/AIDS in mosques, schools, and other public places. This was possible because Somaliland's government provided a secure service delivery environment.

In addition to the provision of basic law and order, Somaliland's government was actively involved in the prevention activities of the project, and contributed to the fact that the population in the region perceived the provision of HIV/AIDS service as a legitimate task. HIV/AIDS education was added to school curricula, and the parliament adopted a law that prohibits discrimination against HIV-infected people. Somaliland's health ministry also helped to overcome the resistance to condoms by promoting their use. At the beginning of the project, the distribution of condoms was heavily delayed because of stigma, but eventually, the project distributed over two million condoms to public and private hospitals by 2009 (data on condom use is unavailable).

With respect to the provision of antiretroviral treatment, at least some results were achieved in Somaliland. In June 2005, the Global Fund project started to treat HIV-infected people with ARVs in Somaliland's capital Hargeisa. This was the first time that ARVs were provided to patients in Somalia. In December 2006, over 100 HIV-infected people were treated with ARVs (UNAIDS 2008), and more than 800 people received ARVs in 2010 (Global Fund 2012c). Compared to other low-income countries in Africa, this is still a small number. Given the limited health sector capacity in Somaliland, this result can be considered a success, particularly in comparison with Puntland, and the South-Central region, where only very few people received ARVs (see below). Different stakeholders reported that Somaliland's relative success in treatment provision is grounded in the more stable security situation of the region.

One major challenge for the provision of HIV/AIDS services was the limited capacity of the health system. There was a significant shortage of health workers, facilities suffered from supply deficiencies, and supervision was lacking due to limited availability of technical assistance. There was no blood bank, and no blood safety policy, no referral system between facilities, no training on ARV adherence counseling, and low epidemiological knowledge. Limited capacities among local implementers (especially NGOs) were also identified by UNAIDS as a major constraint. However, through the Global Fund project, health workers were trained in key service delivery areas, including HIV diagnosis, AIDS treatment, and the diagnosis and treatment of STIs. Within two years, four facilities were able to provide ARVs in Somaliland. Thanks to the stable situation, the establishment of a basic infrastructure was possible.

A HIV/AIDS commission was also established to improve the coordination between the different actors and sectors. Since the development of a country-wide commission was impossible because of the political tensions between the three Somali regions, each region created its own commission as part of the Global Fund project. The “Somaliland AIDS Commission” has developed into a functioning forum, and helped to develop an antidiscrimination law that was passed by the parliament of Somaliland.

Implementation of the HIV/AIDS Project in Puntland and South-Central Somalia

The results of the HIV/AIDS project in Puntland and South-Central remained much more limited. Only few prevention activities were implemented. Health workers lacked the safe environment needed for the implementation of awareness-raising and education campaigns. As a result of the kidnapping industry in Puntland, and the general insecurity in the South, international staff was unable to travel into these regions to help implement the planned activities.

Local staff members were unable to implement the planned project activities because of the strong HIV/AIDS stigma, which made the provision of HIV/AIDS services dangerous. Rather than supporting service delivery, local actors prevented the provision of services out of cultural and religious beliefs. This is a key difference between the TB project and the delivery of HIV/AIDS services in Somaliland, where implementation support was provided by the health ministry, where the government was able to maintain public order, and where it contributed to the generation of legitimacy for HIV/AIDS service delivery. As a consequence, HIV/AIDS remains a taboo; openly promoting the use of condoms continues to be impossible. In 2011, the Deputy Health Minister of the TFG mentioned, “We are not like Somaliland, where I have seen in the media that the people are discussing HIV/AIDS in public” (IRIN 2011). An evaluation of the Gedo Health Consortium—an NGO initiative focusing on health service provision in the Gedo region in the Central South—found that no condoms had been supplied by the project by 2007. The evaluation also reported that no activities were implemented to address the stigma in communities and among staff members (Carlson 2007). As condoms are an extremely sensitive issue, planned behavior change campaigns could not be implemented due to strong taboos and discrimination of people living with HIV/AIDS. Although the ministries of health formally supported condom distribution, there was a strong resistance to the implementation of HIV/AIDS prevention, treatment, and care services in the population. The implementation of HIV/AIDS prevention strategies in the South-Central zone became even more difficult when al-Shabaab gained increasing control of large geographical areas. The distribution of condoms in South-Central became impossible because distributing condoms was not tolerated by al-Shabaab (Global Fund 2012b, 23). This shows that, in addition to the chronic instability, which in itself can represent a major obstacle for effective service provision, the implementation of prevention strategies in Central Somalia was stopped by al-Shabaab. While the HIV project in Somaliland (and to a certain extent) and Puntland distributed 2.5 million condoms to public and private hospitals, the distribution of condoms in Central Somalia failed. Radical Islamic groups, including al-Shabaab militia, increasingly gained control of large areas and did not tolerate the distribution of condoms in these areas.

Implementation of awareness campaigns to educate people about HIV/AIDS and to reduce the stigma was further restricted because of threats from al-Shabaab. The Somali NGO SOPHA that has an office in Mogadishu's government-controlled areas, reported: “In al-Shabaab-controlled areas, we can't hold workshops because they already prohibited international aid organizations to operate in areas they control in south-central Somalia. For this reason, we hold the workshops in the government area” (IRIN 2011).

Expanding ARV services remained a challenge for the project because the poor health infrastructure could not be improved due to the continuing insecurity and the lack of acceptance and legitimacy. By the end of 2007, only two people received treatment in Puntland, and only one person was treated in South-Central Somalia (UNAIDS 2008, 23). Due to the violence, the provision of other forms of capacity building—particularly related to the health workforce—but also regarding other technical support was restricted to nonwar zones. Building up the needed capacity at the community level was also difficult to implement because of the stigma and the turmoil in large parts of the country. The main reason for the variance in the treatment area was the stable security situation in Somalia: “Relief workers attribute the success of the ARV project to the relative stability of Somaliland compared to South-Central Somalia, which continues to be racked by conflict, displacing large numbers of people” (IRIN 2011). The attempt to establish effective multi-sectoral forums also failed. While one committee for each zone was established, the committees were not effectively supporting the response due to the prevailing instability.

Conclusion

  1. Top of page
  2. Abstract
  3. The Role of State Capacity for the Provision of Governance Services
  4. Why Do Task Properties Matter?
  5. Somalia—Service Provision in a Collapsed State?
  6. Effective Provision of Malaria Prevention Services
  7. Effective Provision of Tuberculosis Services
  8. The HIV/AIDS Project—The Challenge of Complex Service Provision
  9. Conclusion
  10. References

The malaria and TB projects of the Global Fund in Somalia are examples of an effective provision of collective goods in areas of limited statehood. Although there are many challenges, both projects demonstrate that simple health services can be successfully provided even if there is no state that exercises effective domestic sovereignty. Through the training of community health workers and the modest demand on the health infrastructure, TB services were effectively provided by the project, even in the Southern region. Equally important, the TB case also points to the role of local legitimacy for effective service delivery. The case indicates that once local actors perceive the targeted services as legitimate, programs can be effective, even under such unstable conditions as in Central Somalia. Local acceptance can create a protective environment for external actors and as such the basis for their operations. Nonetheless, there are indications that the worsening security situation had a negative impact on the TB project. Due to the intensified conflict, the number of case notifications decreased in 2007.

The effectiveness of the HIV/AIDS project remained limited. It only achieved good results in Somaliland, where the regional authorities successfully contributed to the legitimacy of the HIV/AIDS service delivery. The stable security situation, which is based on the state's relatively intact monopoly of force, and the stronger public health infrastructure, are two other key factors for explaining the higher effectiveness of the project in the North-Western region.

In Central Somalia and Puntland, the lack of legitimacy and the resulting resistance of local communities impacted negatively on the project implementation. The local support that can substitute for the lack of statehood was missing. In addition, insecurity, and scarce health capacities slowed down or obstructed the implementation of prevention, treatment, and care activities, demonstrating the difficulties that complex health projects can face, when the monopoly over the use of force is lacking and a functioning health system is largely absent.

Notes
  1. 1

    The period investigated is 2003 to 2010. Travels to Kenya were undertaken in September 2007 and 2008, and in April 2009. Thirty-six stakeholders were interviewed, including representatives from UN organizations, NGOs, bilateral agencies, and the Global Fund.

  2. 2

    In August 2012, the TGF's tenure ended and the Federal Government of Somalia was inaugurated.

  3. 3

    Reliable impact data are unavailable. It is unclear if the distribution of nets had led to a reduction in malaria cases and deaths.

  4. 4

    Funding for the two projects amounted to US$13.8 million and US$22.3 million, respectively.

  5. 5

    Interview with staff from the NGO Cooperazione Internazionale staff, Nairobi, September 2007.

  6. 6

    Interview with Mercy USA staff, Nairobi, September 2007.

  7. 7

    Key informant interview with World Vision staff, Nairobi, September 2008.

  8. 8

    The budgets amounted to US$24.9 million and US$59.6 million, respectively.

  9. 9

    Interview with UNAIDS staff, Nairobi, September 2008.

References

  1. Top of page
  2. Abstract
  3. The Role of State Capacity for the Provision of Governance Services
  4. Why Do Task Properties Matter?
  5. Somalia—Service Provision in a Collapsed State?
  6. Effective Provision of Malaria Prevention Services
  7. Effective Provision of Tuberculosis Services
  8. The HIV/AIDS Project—The Challenge of Complex Service Provision
  9. Conclusion
  10. References
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