COMMUNITY HEALTH AND SOCIAL

ACCOUNTABILITY IN SOMALIA

March 2017
Contents
List of Acronyms .................................................................................................................................................. 3
Executive Summary ............................................................................................................................................. 4
Situation Analysis ................................................................................................................................................ 5
Needs Summary .................................................................................................................................................. 9
Galgadud Region ............................................................................................................................................. 9
Lower Juba region ......................................................................................................................................... 10
Bari region ..................................................................................................................................................... 12
Core problems to be addressed .................................................................................................................... 13
Project Design ................................................................................................................................................... 14
The Decentralized Service Delivery Model ................................................................................................... 14
Project phasing .............................................................................................................................................. 16
Summary of Objectives & Outcomes............................................................................................................. 18
Intervention Strategy...................................................................................................................................... 18
Monitoring & Evaluation ..................................................................................................................................... 24
Coordination ...................................................................................................................................................... 25
Cross Cutting Themes ....................................................................................................................................... 26
Do No Harm / Conflict sensitivity ................................................................................................................... 26
Environment................................................................................................................................................... 27
Stakeholder Participation & Accountability .................................................................................................... 28
Risk Management & Mitigation .......................................................................................................................... 28
Exit Strategy ...................................................................................................................................................... 30
Project Governance & Management Structure .................................................................................................. 31
List of Annexes .................................................................................................................................................. 33

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List of Acronyms
M2M Mother to Mother
ANC Antenatal Care
NDP National Development Plan
ARI Acute Respiratory Infection ORS Oral Rehydration Solution
AWD Acute Watery Diarrhoea OTP Outpatient Therapeutic Program
BCC Behaviour Change Communication PDQ Partnership Defined Quality
Basic Emergency Obstetric and New-
BEmONC PHU Primary Health Unit
born Care
CEFM Child, Early & Forced Marriage PLW Pregnant and Lactating Women
Comprehensive Emergency Obstetric
CEmONC PNC Postnatal Care
and New-born Care
CHC Community Health Committee RHB Regional Health Board
CHW Community Health Workers RHC Referral Health Centre
Community Case Management of Acute
CMAM RHO Regional Health Office
Malnutrition
Reproductive, Maternal, Neonatal and
CMU Consortium Management Unit RMNCH
Child Health
CTC Cholera Treatment Centre RMS Regional Medical Store
DHB District Health Board TBA Traditional Birth Attendant
Therapeutic Supplementary Feeding
DHO District Health Office TSFP
Program
EPHS Essential Package of Health Services
EPI Expanded Programme of Immunisations
F2F Father to Father
FGM Female Genital Mutilation
FPPAC Family Planning & Post Abortion Care
GAM Global Acute Malnutrition
HC Health Centre
HCS Health Consortium Somalia
HMIS Health Management Information System
HSSP Health Sector Strategic Plan
Integrated Community Case
ICCM
Management
Information, Education, and
IEC
Communication
Integrated Management of Childhood
IMCI
Illness
International Non-Governmental
INGO
Organisation
IPC Interpersonal Communication
IYCF Infant and Young Child Feeding
JHNP Joint Health and Nutrition Program
JPLG Joint Program on Local Governance
KAP Knowledge, Attitudes and Practices
MBS Modern Birth Spacing
Monitoring Evaluation Accountability and
MEAL
Learning
MOH Ministry of Health
MNCH Maternal, New-born and Child Health

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Executive Summary
Save the Children has worked in Somalia for over 60 years, and has been implementing health interventions
for over a decade. Our long history in Somalia has endowed Save the Children with a comprehensive
understanding of the local context, experienced and skilled local staff, and established systems and procedures
to effectively implement projects, often in an insecure or unpredictable operating environment. In 2014, following
the merger with Merlin, Save the Children became one of the biggest health actors in the country. In 2016, we
supported over 155 health facilities in 20 districts directly reaching 1 million people. Save the Children is the
largest implementing partner of JHNP and key implementing partner of the CHANGE consortium, as well as the
consortium lead for the DFID-funded nutrition consortium (SNS) and the latest health and nutrition consortium
for the drought response. As such, Save the Children is exceptionally well placed to lead this innovative project
design and achieve meaningful and sustainable results in Somalia.

This three-year programme has the overall objective of the project is ‘Increased utilisation of quality
Reproductive, Maternal, New-born, Child Health (RMNCH) services which are accessible, acceptable,
affordable and equitable through provision of EPHS’. This will be achieved through the following outcomes and
intermediate outcomes: 1: Evidence base of innovative solutions to inform replication and advocacy established;
2: Essential Package of Health Services, including nutrition, family planning and reproductive health, delivered
to women and children; 3: Health governance and management structures strengthened; and 4: Community
ownership, accountability and demand for health services enhanced. It is essential that this project contribute
to the overall objectives and strategic direction of the Government of Somalia. Its proposition for
decentralisation, outlined in the National Development Plan 2017-19, recognizes that decentralized fiscal
arrangement and ultimately service delivery is pivotal in building incremental trust between citizens and local
government, particularly through basic service delivery. This proposed programme will build upon and adapt
Save the Children’s decentralised approach used in the Karkaar Region of Puntland as part of the DFID-funded
CHANGE programme (Community Health and Nutrition through Local Governance and Empowerment)
whereby the decentralized system for the delivery of health care services empowers district authorities, and
communities, while maintaining the support, supervision and accountability role of the regional and national
authorities; as well as ensuring the provision of the Essential Package of Health Services (EPHS) across all
four tiers of services delivery, complemented by a strong community level engagement component, and
flexibility for humanitarian response. To build on achievements made under the Joint Health and Nutrition
Program (JHNP), and ensure continuation of life-saving services to vulnerable populations, this project will be
implemented in the seven districts of Bari region in Puntland, Adado district in Galgadud region, and Afmadow
and Kismayo districts in Lower Juba region.

This programme also has at its core the Doing Development Differently approach. Too many development
initiatives have limited impact. This is because genuine development progress is complex; solutions are not
simple or obvious, those who would benefit most lack power, those who can make a difference are disengaged,
and political barriers are too often overlooked. Many development initiatives fail to address this complexity,
promoting irrelevant interventions that will in the long term have little impact. Development initiatives that have
real successes and results usually involve the same common principles: focus on solving local problems that
are debated, defined and refined by local people in an ongoing process; legitimised at all levels (political,
managerial and social), building ownership and momentum throughout the process to be ‘locally owned’ in
reality (not just on paper); work through local conveners who mobilise all those with a stake in progress (in both
formal and informal coalitions and teams) to tackle common problems and introduce relevant change; blend
design and implementation through rapid cycles of planning, action, reflection and revision drawing on local
knowledge, feedback and energy to foster learning from both success and failure; manage risks by making
‘small bets’: pursuing activities with promise and dropping others.

Ultimately they foster real solutions to real problems that have real impact, and in doing so they build trust,
empower people and promote sustainability. Under this three-year Swedish Embassy and SDC funded
program, Save the Children is committed to apply these principles in our own efforts to pursue, promote and
facilitate development progress, to document new approaches, to spell out their practical implications and to
foster their refinement and wider adoption. As such, our project design is grounded in a strong and embedded
innovation, research and learning agenda so that we are fostering a culture of flexibility, adaptation and
responsiveness whilst ultimately striving towards the overall change we want to achieve over the course of the
project period - improving the reproductive, maternal, neonatal and child health (RMNCH) of women and
children in Somalia. Save the Children is proposing a four-phased project, comprised of an inception phase,
pilot phase, scale-up phase and consolidation and evaluation phase, to allow for effective and meaningful
reflection, feedback and learning throughout the project period to continuously inform the project design -

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pursuing and adapting activities with promise, and dropping others while providing essential lifesaving
interventions in parallel.

Situation Analysis
Lasting for over 2 decades, Somalia is one of the world’s longest running humanitarian crises. The combination
of conflict, insecurity, mass displacement, recurrent droughts, flooding and extreme poverty, coupled with very
low basic social services coverage, has seriously affected food security and significantly increased the
population’s vulnerability to disease and malnutrition. The humanitarian situation in Somalia remains alarming,
with 3.2 million people (two-fifth of the total population) in need of humanitarian assistance 1. There are 1.1
million internally displaced people (IDP) across Somalia; 70-80% of IDPs and refugees are women and
children2. The majority of IDPs are living in congested settlements with limited access to infrastructure and
services; are unable to meet their daily food and non-food needs. About 3.2 million women, girls, boys and men
in Somalia need emergency health services, while 2.8 million women and men require improved access to
water, sanitation and hygiene (WASH)3. The health system remains weak, poorly resourced and inequitably
distributed. Funding for health programmes remains very low and there is critical shortage of capacity for a
health workforce - there are only about 6,300 doctors, nurses and midwives working in Somalia 4, which based
on a population of approximately 12 million people, is about 1,900 people per health personnel. The shortfall in
funding is already jeopardizing provision of health services and putting the health of the affected communities
at dire risk. In addition to long distance to health facilities, lack of drugs and equipment, lack of services, absence
of personnel, and unqualified/unskilled personnel have been cited in multiple studies as major barriers to
utilisation of public health services. As direct service provision by the Somali health authorities was marginal for
many years, the gap was filled by the private sector which has become the dominant provider, delivering over
60% of health care services in Somalia 5. The use of pharmacies account for the vast majority of all private
sector health seeking, with one study finding that of the 49.7% of respondents who utilised private sector health
services when a household member was ill, pharmacies alone constituted 44.8% of services utilised 6.

In addition to the analysis below, Save the Children will expand the information further during the in-depth
context analysis during the inception phase which will help to inform, shape and prioritise the package of
interventions per target location.

Health Systems
The Health Sector Strategic Plan (HSSP) Phase II (2017-2012) is the most relevant framework related to health
systems strengthening in the country. 7 The other policy and frameworks that are relevant in designing and
reshaping the project are National Development Plan, National Decentralization Policy, Human Resource for
Health (HRH) Development Policy. Although there are big gaps in terms of proper policy and regulatory
framework, there have been a number of policies adopted (or being developed) such as National Health Policy,
Medicine Policy, Essential Package of Health Services, Expanded Programme on Immunization (EPI) etc. See
Annex – Context Analysis of Health System Building Blocks, which summarises the current status and strategic
priorities for health systems strengthening of the country, and their relevance to developing a dynamic project.

Maternal and New-born Health

Over a Somali woman’s lifetime, she will face a one in 18 chance of dying from causes related to pregnancy or
childbirth. The maternal mortality ratio (MMR) in Somalia is 732 per 100,000 live births, among the world’s
highest, with Somalia ranked as the worst place in the world to be a mother in Save the Children’s 2016 State
of the World’s Mothers report, although the MMR is down from 1210 in 1990) 8. The average fertility rate is 6.6
children per woman with unmet need for birth spacing at 26%. Access to maternal health services is low with
44 and 38 per cent of births in Somaliland and Puntland being attended by skilled birth attendants. Only 25%
of women receive professional antenatal care with only 6% attending more than the recommended 4 visits.
Reproductive health services are weak in Somalia, inhibited by both supply and demand. This applies to modern
FP services, ANC, facility-based delivery, PNC, STI and HIV testing. The 2006 MICS clearly indicated that many
women experience major health problems during the postpartum period, while only 10 to 12 percent of Somali

1 UNOCHA Humanitarian Needs Overview 2016

2
UNDP 2012
3 UNOCHA Humanitarian Needs Overview 2016
4 UNOCHA Humanitarian Needs Overview 2016
5 DFID. Assessment of the private health sector in Somaliland, Puntland and South Central (March 2015)
6 Lynch C. Report on Knowledge Attitude and Practices for Malaria in Somalia. UNICEF/ Global Fund Partners. Malaria Consortium. February 2005

7 MOH, Second Phase Health Sector Strategic Plan, Draft (Jan) 2017
8http://www.unicef.org/somalia/health.html

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women report having sought any post-natal care9. Neonatal Mortality is 40/1000 live births which is twice as
much as the global average and the third highest globally10.

Gender-based violence in Somalia is widespread. Women and girls from displaced populations are more at risk
of SGBV, especially those from minority clans and female-headed households. Traveling long distances to
collect firewood or to distribution points for water, food or other materials further exposes women and girls to
the potential for sexual and physical assault. According to the WHO, approximately 98% of women in Somalia
undergo Female Genital Mutilation (FGM) 11, and it is mostly performed on girls between the ages 4 to 11 years
in its most severe form; infibulation is reported to be practiced in 80% of cases 12. As such, women and girls are
more likely to suffer serious immediate and long term health implications, including death, urogenital tract issues
and adverse obstetric outcomes.

Girls are also married early across Somalia, with 45% of women aged 20 to 24 married before the age of 18 13.
This combined with the value placed on large families, their inability to negotiate safer sex with their partners,
typically results in early sexual debut and onset of childbearing. This is associated with negative maternal health
outcomes related to frequent childbirth and unplanned pregnancies with first time pregnancies particularly
associated with high rates of maternal mortality, obstructed labour, pregnancy-induced hypertension and fistula.
The young age of mothers also compromises the health of their babies, with a dramatically increased risk of
neonatal and infant mortality related to birthing difficulties, poor feeding practices and less consistent well-baby
care practices, such as vaccination.

Child Health
The under-five mortality rate (U5MR) is 137 per 1,000 live births with one in seven Somali children dying before
they reach their fifth birthday. Although there has been some progress in recent years in reducing infant and
child mortality, it remains unacceptable high, particularly in central and southern parts of the country. Even in
places where health services are provided free of charge, utilisation rates remain low due to caregiver
preference for traditional health providers or the unregulated private sector; lack of available services outside
accessible urban areas, perceived low quality of services provided through public facilities and cost of accessing
health services (perceived or otherwise). The leading causes of under-five mortality are acute respiratory
infections (ARI) including pneumonia (24%), diarrhoea (19%), neonatal disorders (17%), and measles (12%) 14.
Overall rates of immunization coverage remain low in Somalia, with an estimated coverage for measles and
DPT3 of well under 50 per cent in 2014 15. Furthermore, there are poor health care seeking behaviours by
caregivers with only 13% of children suspected of having pneumonia being taken to a health care provider 16,
as well as poor access to and/or use of Oral Rehydration Solution and zinc for diarrhoea management. Infant
and Young Child Feeding (IYCF) practices in Somalia are sub optimum with 26% and 9% early initiation and
exclusive breast feeding rates respectively. The overall burden of acute malnutrition in 2016 is estimated to be
more than 800,000 cases17. In internally displaced persons (IDP) settlements, global acute malnutrition (GAM)
rates are frequently above the emergency threshold of 15 per cent 18 . Acute malnutrition, micronutrient
deficiency, as well as poor access to potable water, poor personal hygiene practices and open defecation are
major underlying causes of under-five morbidity and mortality. Poor infant and young child feeding (IYCF)
practices, including lack of exclusive breastfeeding, are major contributors to high and persistent malnutrition
levels.

Barriers to demand for and utilisation of health services

Despite the implementation of EPHS, health service utilisation in Somalia remains very low. On average,
Somalis only use health facilities once every eight years 19. Indeed, recent health facility utilisation rates in EPHS
(JHNP) regions20 are as low as 0.13 new consultations per person per year in Galgadud, 0.43 in Nugal, 0.45

9 http://www.unicef.org/somalia/SOM_HealthcareseekingbehaviourReport_10-WEB.pdf
10 http://www.who.int/gho/en/ , http://www.who.int/gho/en/
11 World Health Organization. Female Genital Mutilation and other Harmful Practices: Prevalence of FGM. Available from

http://www.who.int/reproductivehealth/topics/fgm/prevalence/en/index.html
12 United Nations Development Programme (2007). United Nations Development Programme (2007) Millennium Development Goals Report for

Somalia, p.26. Available from http://www.so.undp.org/MDG%20Report%20for%20Somalia%20English%20Version.pdf

13 United Nations Development Programme (2012). Somalia Human Development Report 2012: Empowering Youth for Peace and Development
14
UNICEF. (2014) Somalia Annual Report 2014.
15
UNICEF Somalia. Situation Analysis of Children in Somalia 2016
16 UNICEF Somalia. Situation Analysis of Children in Somalia 2016
17 2016 Humanitarian Response Plan
18 UNOCHA Humanitarian Needs Overview 2016
19
MICS, 2006
20
JHNP Annual Report 2014

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for Awdal, which are far below global recommendations 21 . Indeed, there is a unique mix of availability,
accessibility and acceptability of health facilities combined with socio-cultural, gender and environmental
determinants which form a series of barriers to health prevention and care in the Somalia context:
 ACCESS: Population density in Somalia is low – just 25 people per square kilometre - making the
provision of static health services difficult. Access to public health services in rural areas is very limited
with less than 15% of rural inhabitants having access to any healthcare provider 22 . Pastoralist
communities, accounting for 65% of the population in Somaliland and Puntland, face the greatest
obstacles to accessing both public and private facilities due to their nomadic/migratory lifestyle. They
reported lower use of almost all types of health facilities, and were more likely than all other groups to
do nothing when a child fell ill (with 62% of pastoralists seeking no treatment for a child with fever and
cough, compared to 36% in rural communities and 13% in urban communities) 23. There are 1.1 million
internally displaced people living mainly in the outskirts of urban towns constitutes 8.6% of the total
population. The key high-risk groups are 2.4 million children under the age of 5 years and more than 3
million women of child bearing age. At one time there are about 593,000 pregnant women in the
country24
 KNOWLEDGE: The role of knowledge cannot be ignored when examining motivations and barriers to
health seeking behaviour. Without knowledge or previous exposure, the benefits of essential services
cannot be internalised and prioritised by a community. Research25 indicates that lack of knowledge and
awareness of preventative services, such as antenatal care, danger signs in pregnancy, birth spacing
methods, and positive IYCF practices, are particularly important barriers to health service utilisation.
 QUALITY: Lack of drugs and equipment, absence of personnel, and unqualified/unskilled personnel
have been cited in multiple studies as major barriers to utilisation of public health services. This has
resulted in negative attitudes towards health services, low expectations, a history of bad experiences,
and a level of mistrust by the local populations these health facilities serve. In focus group discussions
supported by Save the Children, respondents shared that although they raise issues, concerns and
suggestions with the MOH, their voices are not being heard, further entrenching the disconnect between
the health facility and the community.
 TRADITIONAL HEALTH ACTORS: For centuries, Somali society has entrusted their health to
traditional healers, including traditional birth attendants (TBAs), who remain a highly respected and first
treatment preference for many, particularly amongst pastoralists (around 30%) 26.
 PRIVATE ACTORS: As direct service provision by the Somali health authorities was marginal for many
years, the gap was filled by the private sector which has become the dominant provider, delivering over
60% of health care services in Somalia27. Private sector services are particularly used in urban centres
where there is greater diversity in the range and sophistication of private services available to a
population with the financial means to use them 28,29. Pharmacies account for the lion’s share of all
private sector health seeking with one study finding that of the 49.7% of respondents who utilised private
sector health services when a household member was ill, pharmacies alone constituted 44.8% of
services utilised30.
 GENDER: The Gender Inequality Index for Somalia is 0.776 (where 1 denotes complete inequality),
placing Somalia the 4th worst globally31. Decision-making power appears to be variable in different
cross-sections of Somali populations, and overarching trends are difficult to identify. According to
research, typically, the mother initiates decisions around the health of the family. Men tend to make
decisions when the wife is sick and in need of referral for treatment where permission from the husband
(or the husband’s male relative if he is not available) is required, certainly if expenditure is involved.

21
Sphere Handbook: There is no minimum threshold figure for the use of health services, as this will vary from context to context. Among
stable rural and dispersed populations, utilisation rates should be at least 1 new consultation/person/year. Among disaster-affected
populations, an average of 2–4 new consultations/person/year may be expected. If the rate is lower than expected, it may indicate
inadequate access to health services.
22
Health Sector Strategic Plan for Puntland
23
Save the Children. The First Mile: Analysis of demand for health system in Karkar region of Puntland (2014)
24 Central Government of Somalia National Development Plan Summary. (2017) pg. 57
25
UNICEF. Formative Research on Behaviour and Communication Barriers in Somalia (2015)
26
Save the Children. The First Mile: Analysis of demand for health system in Karkar region of Puntland (2014)
27
DFID. Assessment of the private health sector in Somaliland, Puntland and South Central (March 2015)
28
UNICeF Somalia. Somaliland Private Pharmacy Situation Analysis. May 2009
29
Save the Children. KAP study on health in pastoral communities in Puntland (2014)
30
Lynch C. Report on Knowledge Attitude and Practices for Malaria in Somalia. UNICEF/ Global Fund Partners. Malaria Consortium.
February 2005
31UNDP 2012, Gender Equality Brief
http://www.undp.org/content/dam/rbas/doc/Women's%20Empowerment/Gender_Somalia.pdf

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Progress in the sector
In recent years there have, however, been positive developments in the Somali health sector with the
establishment of Ministries of Health (MOH) and the development of the Somali Health Policy (2014), Health
Sector Strategic Plans (2013-2016) and Community Health Strategy, amongst others. These have informed the
development of the Health and Nutrition chapter of the National Development Plan (NDP) 2017-2019, which
prioritises the provision of EPHS, health systems strengthening and achievement of the health related
sustainable development goals. Key principles of the NDP are universal and equitable access to acceptable,
affordable, cost-effective and quality health services; transparent and accountable governance and leadership
in managing different components of health system with decentralized management of health care service
delivery; building effective collaborative partnerships and coordination mechanisms engaging local community,
national and international stakeholders and pursuing aid effectiveness approaches. There has been the
restoration of public health services through the implementation of the EPHS, provided free of charge to users,
through two large programmes which focused on delivery of EPHS from 2012 to 2016:

 The DFID-funded HCS was managed by PSI in consortium with four INGOs, including Save the
Children, implementing in three regions in each of what was referred to as the three zones of Somalia.
It aimed to improve the health of Somalia through increased utilization and access to reproductive,
nutrition, child and maternal health services including through the private sector with the expected
results of reduced under-5 and maternal mortality rates. HCS closed in March 2016 with an A+ rating
from DFID. A new DFID-funded project, CHANGE, has commenced and is being implemented in the
same regions by the same consortium partners for a five-year period (2016-21).
 The JHNP, a donor pooled fund, was managed by the UNICEF in partnership with the MOHs in the
three zones and donors and also sought to increase use of RMNCH and nutrition services across
WHO’s six building block of health systems strengthening. JHNP is implemented in 9 regions across all
three zones of Somalia. Save the Children is the largest implementing partner for JHNP covering 15
districts. JHNP will end in April 2017 with its donors individually determining their own modalities for
supporting the health sector from 2017 onwards.

Lessons learnt from JHNP and HCS

JHNP and HCS performed different functions in health systems strengthening but comparisons have been made
between them regarding their deliver of EPHS in terms of unit costing and value for money 32. Given Save the
Children’s role as largest implementer of both JHNP and HCS, it has a unique perspective with regards to the
strengths and weaknesses of both programmes, which are presented here and have been taken into account
in the design of this proposal. The following differences between the two programmes were elaborated through
a series of consultations between Save the Children programme staff, other INGOs and MOH:
 Governance structure: A key difference between JHNP and HCS was the role that NGOs were
expected to play and consequent effects on their capacity to implement programmes that responded to
community needs. In JHNP, UNICEF managed the EPHS service delivery component by sub-
contracting to NGOs for delivery of a proscribed package of services. NGOs did not have any form of
representation on the Steering Committee or Technical Coordination Groups except on paper and were
therefore limited in their capacity to provide direct feedback to donors and MOHs and were far removed
from key decision-making processes. By contrast, as one of the three INGOs implementing EPHS as
part of HCS, Save the Children and other consortium members were key participants in the quarterly
and annual review meetings with the donor (DFID) and MOHs and therefore able to provide to provide
direct feedback and contribute to key decisions. The need for implementing INGOs to have a strong
role in decision-making and close relationship to the donor was recognized and in the next phase of
HCS (CHANGE), a Steering Committee compromising of all INGOs, MOH and DFID will guide the
programme. One strength of JHNP was the production of various key policy and strategy documents
even if MOH capacity to roll them out was a challenge.
 EPHS Roll Out: Key issues for JHNP were long delays in EPHS rollout. Save the Children was the
rationalized partner for ten districts in each of the 3 zones, across five of the seven new federal states.
Heavy bureaucratic processes resulted in long delays for contracts which were initially for only one
year, with gaps between contracts resulting in partners being forced to continue services without
receiving funds from UNICEF. Under HCS there were no delays in funding to hamper implementation.
 EPHS Delivery: EPHS including nutrition services (although somewhat limited) was delivered at the
PHU and HC levels only in JHNP whereas there was limited integration of nutrition in HCS. However
JHNP focused on only two out of the six core components delivered with limited interactions at the
community level. The package was also quite strictly proscribed with implementing partners lacking the

32 SIDA 2015. Mid-term Review of the Somali Joint Health Nutrition Programme (JHNP).

8
 flexibility to adapt delivery to their specific context as well as emerging issues, limitations in the amount
of health facility rehabilitation or construction that could take place as well as capacity to pilot different
initiatives to increase quality of services and utilization rates. The focus was on delivery of free services
rather than other measures to ensure increased uptake of services through demand creation activities
tailored to the specific needs of communities. The greater flexibility that implementing partners were
able to exercise under HCS was another key factor in its success. Save the Children had the flexibility
in budgeting to be able to respond to the effects from a cyclone and was also able to pilot and integrate
different innovative approaches such as ICCM and IPC to increase demand for services. A full package
of EPHS was delivered from community to PHU, HC, RHC and district hospital levels including providing
CEmONC services (although this did not include nutrition services).
 Supply Chain: Under JHNP UNICEF was responsible for central procurement and distribution of
supplies and drugs, which functioned often through a push system which provided PHU and HC kits on
a quarterly basis. This resulted in long delays, stock outs and partners pushed to take drugs with short
shelf lives not to mention the significant delays at the start of the programme. Under HCS each partner
was responsible for their own procurement and was therefore able to ensure more responsive and
timely procurement.
 Regional approach: In HCS, Save the Children was the sole implementing partner in Karkaar region,
which enabled development and strengthening of the Karkaar Model of regional delivery of health
services (which will be further explored below) through more sustainable investments in regional
structures including the financing system. Under JHNP the focus of capacity building by implementing
partners was on health facility and district level MOH staff to some extent, but did not include regional
or state-level capacity building, focusing rather on the central level (the three MOHs). There was no
additional funding or imperative under JHNP to build MOH capacity at the regional level, although Save
the Children was the sole provider of health services in some districts or region and could have
potentially implemented a regional or a district approach if the flexibility and funding had been available.
 Capacity building: JHNP provided health staff training through a mix of classroom training and
“learning by doing”. It was found that capacity building under HCS was more comprehensive through
on-the-job training with mentorship, supportive supervision and a greater degree of flexibility to change
the training when it was found to be ineffective. Monitoring implementation was also found to be more
effective using the third party monitoring tool developed by IBTCI, rather than the less elaborate EPHS
Scorecard system and joint supervision through JHNP.

Needs Summary
In addition to the analysis below, please also see Annex – Needs & Gaps per Building Block for further details
per target location, as well as Save the Children contribution to date, and the contribution of other actors. It
should be noted that this analysis is not extensive or exhaustive and Save the Children will expand the
information further during the in-depth context analysis during the inception phase which will help to shape and
prioritise the package of interventions per target location.

Galgadud Region
Adado District
Adado District in Galguduud region is in the emerging federal state of Galmudug. The population is an estimated
61,000 people including an increasing number who have been internally displaced by inter-clan conflict or
families hit by drought from parts of Galgaduud region. Maternal mortality rates are exceptionally high -
850/100,000 - compared to the national average of 732/100,000. Only 3.3% of women attend ANC1, 2.5%
attend PNC and only 9.2% of births take place in a health facility attended by skilled birth attendant. In 2011,
70% of children did not receive any vaccination and only 1.4% received all antigens. Acute watery diarrhoea
(AWD) and pneumonia are the major causes of morbidity and mortality among children under five, however,
only 40% of children with diarrhoea received oral rehydration solution and only 43% of children who sought care
for pneumonia received antibiotics. Only 2.6% of infants are exclusively breastfed, and just half of children 6-
23 months receive the recommended minimum meal frequency. According to Save the Children’s needs
assessment in Adado, people typically seek treatment from drug stores or pharmacies (35%), followed by
community health workers (19%), then home treatment (17%). Only 8% said they sought treatment form a
qualified doctor. The main barriers to accessing health care in Adado included: distance to the health facility
(100%), indeed respondents reported travelling an average of 3.2km to reach the nearest hospital;
transportation costs (92%); and long waiting times (72%). Although 92% reported being satisfied or very
satisfied with the service provided. With regards to a location specific gender analysis in Adado, this will be
conducted at the beginning of the project period as part of the in-depth analysis of the context.

9
In Adado district, Save the Children is the lead health and nutrition partner and has been delivering EPHS
through JHNP since 2014. EPHS has been delivered in Adado district through 8 facilities - Adado General
Hospital (which is actually defined as a RHC under EPHS Framework rather than a hospital as services include
CEmONC but do not include more specialized services); two HCs (Godinlabe and Bahdo); five PHUs (Gidheys,
Kahandho, Bwodadhogre, Ado-Kibir and Dagahdeer) – with a catchment population of 35,028, of which 12,399
are children under 5 and 14,259 are women of child bearing age. The health facilities are supported by three
mobile outreach teams which provide integrated community case management (ICCM), Nutrition, and
Expanded Program of Immunisations (EPI) services in communities. Between January and October 2016, Save
the Children has provided 18,684 outpatient department consultations, on average 1,868 per month (although
has peaked at 2,200); 999 pregnant women attended 1st ANC with 467 attending 4th ANC; 960 deliveries were
attended by a skilled birth attendant; 1,607 women received PNC; 1,465 children were immunised for measles;
876 children under were treated for acute malnutrition (724 for MAM and 152 for SAM); and 821 health
education sessions were conducted at health facilities and at the community level.

Other key achievements include:

 Save the Children has established a District Health Office (DHO) with EPI, Infant & Young Child Feeding
(IYCF), Nutrition and Health Management Information System (HMIS) units and is supporting MOH staff
through provision of incentives. A gender-balanced District Health Board (DHB) has also been
established which includes MOH staff and elected community members who make provide oversight,
fundraise and make key decisions on health issues affecting the community. CHCs have also been
established at the health facility level to provide oversight of health services.
 The appropriate health facility staff and community outreach workers have received a number of
trainings including IYCF, Integrated Management of Childhood Illnesses (IMCI), ICCM, HMIS, social
mobilization, BEmONC, IMAM and Prevention of Mother to Child Transmission (PMTCT). However, it
should be noted that one key issue with the health workforce is that the majority of them are not from
the local community, most are from Mogadishu or elsewhere, so it is a struggle to retain them,
particularly as the EPHS framework does not include extra allowance for staff working in remote
locations.
 The community play a strong role in facilitating health service delivery in Adado. The DHB has
successfully undertaken a significant number of fundraising activities locally and with diaspora to
support caesarean section services in Adado Hospital; laboratory supplies and salary top ups for
medical doctors (approximately 30% of their salary).

Lower Juba region

Lower Juba region has faced over two decades of continuous conflict and instability with no formal governance
system. Successive droughts, and limited humanitarian assistance resulting from insecurity have significantly
weakened people’s livelihoods and significantly reduced their coping strategies. Some areas remain under the
control of Al Shabaab, restricting humanitarian access. However, joint efforts between government forces and
the African Union Mission in Somalia (AMISOM) have already liberated some locations and are expected to
increasingly open up more areas for improved access in the near future.

Afmadow District
Dhobley town has an estimated population of 74,852. It already hosts over 17,000 IDPs and due to its proximity
to the Kenyan border (just 4km) it is the main transit town into Somalia and currently experiencing frequent and
massive movements of returnees from Dadaab Refugee Camp in Kenya. Although the majority of returnees
make their way to Kismayo and other parts of Somalia, many are now returning and settling in Dhobley – 1,364
individuals since January 2016 33 - putting additional pressure on already insufficient and over-stretched
resources. Afmadow town has a population of around 88,000 and is 157km from Dhobley and 120km from
Kismayo and was recovered from Al-Shabaab in 2012. Since then it has experienced drought, flooding,
waterborne diseases and IDP arrivals from other locations in Middle and Lower Juba 34. Water shortages and
disease outbreaks, including AWD/Cholera, are common with AWD/cholera spread between Dhobley and Diff
(another town) and Liboi on the Kenyan side of the border. Save the Children has been leading the cholera
response in Dhobley and in the past 3 months a total of 363 cases were treated using standard case
management and all were discharged cured with no death reported. According to a recent assessment carried
out by Solidarity International in Dhobley town, 13% of the respondents had someone in their family suffered
from diarrhea in the past 2 weeks.

33 UNHCR Weekly Update: Voluntary Repatriation of Somali Refugees from Kenya

34 Interagency Rapid Assessment Report; IDPs in Afmadow Town July 2016

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The findings of an interagency report (July 2016) indicate that the District Hospital is in very poor condition,
manned by local volunteers and recommended that an organisation that could manage the hospital be
immediately identified. There is currently no District Health Office (DHO) in Afmadow District. The Jubaland
MOH is also very nascent and has not yet developed structures or systems in all regions in Jubaland. The MOH
has appointed two focal points, one in Afmadow Town and one in Dhobley although they do not currently have
offices or coordinate work on district health issues. Specific units, such as the EPI, IYCF and HMIS units that
exist in Adado or Karkaar, do not exist in Afmadow and a DHB which links MOH to the community has also not
been established. The general capacity of health staff is quite low as there were no training institutions in the
district so most of the health workforce is comprised of returnees from Dadaab (in Dhobley). There is current
no community health service and with only facility-based services provided with the exception of IOM and ARC
which have mobile clinics in Degelema and Tula Barwaqo. In Dhobley town there are two other NGO-run
facilities and several unregulated private clinics and pharmacies. However, the community prefer to use Dhobley
Hospital which Save the Children has been supporting since its merger with Merlin in 2013 (which offers RHC
services and would not be defined as a Hospital under the EPHS framework) as they trust the quality of drugs,
staff and free services.

There is currently no MOH supply chain system in place including a district medical store. All NGOs have their
own procurement systems to bring items mainly from Kenya. There is no HMIS system in place for the district,
including an MOH HMIS officer. Currently the head nurse from each facility compiles health data and submits
to their partner organisation. Interestingly, according to Save the Children’s needs assessment, people typically
seek treatment from a qualified doctor (53%), with 71% stating they had access to a mobile clinic, and 53% to
a maternal and child health centre. 100% of respondents reported being satisfied or very satisfied with the
service provided, and only 13% reporting long waiting times as a barrier to using health services. Only a small
proportion (10%) stated seeking treatment from drug stores or pharmacies. With regards to a location specific
gender analysis in Afmadow, this is already planned ot be conducted under a GAC (Canada) funded health,
nutrition and WASH project that will complement this Sida and SDC-funded project in Afmadow district. The
findings of the gender analysis will be used to inform both projects.

In Afmadow district, Save the Children has been delivering EPHS through JHNP in Dhobley and Diff since late
2015. During 2016, Save the Children provided 31,632 OPD client/patient visits (includes both first visit and re-
attendance); 2,408 children under the age of 5 years were diagnosed and treated for ARI; 1,499 pregnant
women benefitted from ANC1; 499 deliveries were assisted by skilled birth attendants in the facilities; 529
children were immunized against BCG; 39 health education sessions were conducted at the health facility level.
Other key achievements include:
 Health facility staff in Dhobley and Diff are being supported by Save the Children and have received
some training in BEmONC, CEmONC, laboratory safety, focused ANC and IMCI, however there have
been no coordinated district-level trainings.
 CEmONC services are provided through Dhobley hospital (supported by Somalia Humanitarian Fund
(SHF) although this funding has now ended). Prior to this, there were no CEmONC services or even
referral services provided for over 300 kilometres between Kismayo and Dadaab with obstetric
emergencies requiring caesarean sections from Dhobley transported over 110 kilometres over the
border using poor roads to Dadaab. Save the Children has also lead the cholera response during May
to August 2016.

Kismayo district
Kismayo is the third largest city in Somalia and the capital city of Lower Juba region. The port city is the
commercial capital of the autonomous Jubaland region and southern parts of the country. As of 2016, the local
population in Kismayo town is estimated at 183,300 people. Kismayo has in the past 2 years experienced
recurrent droughts, seasonal floods, water borne disease outbreaks, malnutrition, inflation and conflicts. A large
number of both IDPs and returnees have settled in Kismayo district, located in Lower Juba, which hosts a total
of 79 IDP sites, among the largest number in Somalia. Some of the IDP were established immediately after the
fall of the Somali Central Government in 1992. IDPs have also started arriving in the area more recently as a
result of prolonged drought and pressure from Al-Shabab in their area of origin, as well as the arrival of returnees
from Dadaab refugee camp in Kenya, as a result of the voluntary repatriation process. To date, 14,417 returnees
have arrived in Kismayo 35 , thereby putting additional pressure on already overstretched resources and
inadequate infrastructures and social services.

35 Weekly Update: Voluntary Repatriation of Returnees to Somalia (9th December 2016) UNHCR

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Households in Kismayo have reported a very low percentage of vaccinations among children, 21% measles,
16% BCG, 21% polio, 15% DTP36. Findings indicates that while there are wide range of functioning health
facilities, they are understaffed and lack essential equipment and experience shortage of drugs; 21.8% stated
not accessing a functional a health care facility. An assessment of IDPs in Kismayo claims that a total of 54%
of the respondents indicated receiving treatment from hospitals whereas almost 30% of the respondents
reported having received no medical care at all 37.

Acute malnutrition has worsened and remains high due to the numerous shocks experienced. The Global Acute
Malnutrition (GAM) prevalence among Kismayo IDPs based on WFH Z scores is 15.2% and the Severe Acute
Malnutrition (SAM) is 5.8%38. This shows a deterioration of the Nutrition situation in Kismayo when compared
to Gu 2015 (GAM 12.5% and SAM 2.8%) and Deyr 2015 (GAM 12.9% and SAM 2.9%). According to an inter-
agency needs assessment (December 2016), 62% of respondents acknowledged a deterioration of the
nutritional status among children and women. The current GAM rate could be attributed to a number of
multifaceted factors such as; decline in food security situation, disease and inadequate health services as well
as poor sanitation practices, inappropriate feeding and child care practices, and insecurity. 72% said they have
heard of but not having access to targeted nutrition programmes in Kismayo. Most of the breastfeeding practices
in Kismayo IDP Camps are sub-optimal. Results of the survey indicated that awareness on recommended infant
and young child feeding practices was very low with 85% of the mothers interviewed never receiving any form
of education on IYCF. The exclusive breastfeeding rate stands at 15%. Lactating women in the IDP camps are
engaged in menial jobs to fend for their families restricting exclusive breastfeeding. Kismayo nutrition services
for both host and IDPs are run by different Local and international organizations such as PAC, ICRC, SRCS,
Somali AID, SAF UK and Himilo foundation. Most of these organization provide stand-alone nutrition programs,
either OTP or SFP. Kismayo has 2 Stabilization Centres run by ICRC and PAC with a bed capacity of 150 and
80 respectively. In the last quarter of 2016 the stabilization center admitted a total of 553 severely acutely
malnourished children with medical complications. The OTP Services are provided through 10 OTP sites in
Kismayo. With the current high burden of malnutrition in Kismayo, the nutrition coverage seems to be poor. The
Targeted Supplementary feeding program (TSFP) in Kismayo is supported by only 2 organizations (Himilo and
Somali Aid). However, during the time of the assessment 39 there were no active TSFP programs that were on
going in Kismayo. The Ministry of Health (MoH) does not do direct implementation of the nutrition activities but
it supports and contribute to the coordination mechanisms for the Nutrition and Health sector by ensuring
efficient and effective collaboration between different stakeholders in the region.

Bari region
Bari region is situated in the northeast of the autonomous state of Puntland in Somalia. In terms of land mass
it is the largest region in the Federal Republic of Somalia covering an area of 64,500 sq Km. The region is split
into seven districts: Bossaso, Ishkushuban, Qandala, Alula, Carmo, Ufayn and Bargal with a total population of
719,51240. Maternal, under -five and neonatal mortality rates are very high at 732/100,000 live birth, 137/1000
live birth and 61/1000 live birth respectively. Deaths in women and children are largely due to preventable
causes such as hemorrhage, eclampsia, maternal infections, pneumonia, diarrhea, malaria, neonatal
morbidities and vaccine preventable diseases. The unmet need for contraception is 10% in Bari region and
only 0.1% of women 15-49 years have access to a modern method of contraception41. Similarly, only 6.9% of
women attend the first antenatal care visit and 4.4% of women attend all four ANC visits. Most deliveries are
attended by a traditional birth attendant at home as only 17.2% of deliveries happen in health facilities. Access
to routine immunization services is poor; only 10% of children between the ages of 0-23 months have received
the third dose of the DPT (Diptheria, Pertussis, and Tetanus); 26% were vaccinated against measles, and less
than 5% had received all the recommended vaccines 42. Coverage for treatment of common childhood illnesses
is equally poor; of the children who had diarrhea only 44% received ORS and 2.6% had zinc. Of those who had
pneumonia, only 38% were taken to an appropriate health provider of which 53% received appropriate
antibiotics.

Infant and Child nutrition practices are also poor. For example, 54% of neonates were fed within 1 hour of birth;
6.2% were exclusively breast fed, while 17.3% were continually breast fed at 2 years as per WHO

36 Multi-sector assessment of IDP settlements in Kismayo (December 2016) REACH

37 ReDDS Durable Solutions Framework for Lower Jubba (December 2016)
38 SMART Survey among Kismayo IDPs (November 2016) CARE International
39 SMART Survey among Kismayo IDPs (November 2016) CARE International
40 UNFPA’s Population Estimation Survey (2014)
41 Multiple Cluster indicator survey for Puntland
42 Multiple Cluster indicator survey for Puntland

12
recommendation. Furthermore, just over a quarter of the children surveyed received the minimum
recommended meal frequency, and 29% had received vitamin A supplementation in the last six months prior to
the survey. Open defecation and poor hygiene practices are a common practice, as only 42% of the population
of Bari have access to improved water source and 67% have access to sanitation facilities. The outcome of this
interplay between poor health, nutrition status, and WASH conditions are high levels of child malnutrition and
deaths.

Like the rest of Puntland, the health system in Bari weak with huge gaps in infrastructure, inadequate qualified
and poorly distributed human resources, health financing and service delivery. The public health delivery system
is tiered, comprising of a regional referral hospital (located in Bosaso), five Referral Health Centres (RHCs), 18
Health Centres (HCs), and 39 Primary Health Units (PHU). Almost all supported through donor funds. The
distances of the RHCs and HCs to the regional hospital vary widely. Alula, Bargal and Qandala are regarded
as the most remote districts in the region. On the other hand, the RHCs and HCs in Ufeyn, Iskushuban and
Armo are accessible by tarmac road linked to Bosaso town. The regional hospital until recently (Quarter 1 2016)
was supported to provide free emergency obstetric care services with funds from UNFPA, however with this
support gone these services were no longer available free of charge to poor and vulnerable women across the
region. Despite INGO support, operating standards vary greatly across the different levels of service delivery,
and often facilities are not able to meet the recommended EPHS standards for level of care with very low
utilization rates. As a result, the overall coverage of essential health services is low, especially for rural and
nomadic populations. Similarly, majority of the health personnel are concentrated in major towns, leading to
shortage of qualified workers in rural areas. The medical supply chain system is fragmented and maintained
largely by medical supplies from UNICEF and other UN agencies. There is no regional warehouse for the
storage and distribution of medical supplies, and the system for tracking consumption of medical supplies is
weak. In the absence of an efficient and adequate public health system, the private commercial sector has
flourished but remains unregulated with doubtful quality of services and poor access to the rural population.

The approval of the EPHS project in mid-2015, provided much needed respite to the population in Bari region
as it improved access to basic reproductive, maternal, child health and nutrition services. Prior to the
commencement of the EPHS project health services barely existed in those areas. Under JHNP, Save the
Children has been supporting 5 RHCs, 8HCs, and 34 PHUs across 6 districts of Bari - Alula, Armo, Qandala,
Bargaal, Ishkushuban and Ufayn. HMIS data showed a utilization rate of 0.63 visits/per person per year for the
targeted population. During 2016, Save the Children provided 112,852 OPD client/patient visits (includes both
first visit and re-attendance); 10,591 children under the age of 5 years were diagnosed and treated for ARI;
6,961 pregnant women benefitted from ANC1 of which 2,656 reached ANC4; 1,685 deliveries were assisted by
skilled birth attendants in the facilities; 13,031 children were immunized against measles; 552 health education
sessions were conducted in the communities, and 407 at the health facility level.

Core problems to be addressed

Based on the analysis above, the main problems that will be addressed include:
 Poor governance and leadership: The Jubaland and Galmudug MOHs are very nascent and has not
yet developed structures or systems in all regions. In particular there is no district level MOH at all
currently in Afmadow and only a recently established district level MOH in Adado. Improving
governance and leadership for health is one of the priority building blocks of the Health Sector Strategic
Plan (HSSP) and fundamental for the effective management and oversight of the EPHS. The
government recognizes that more is needed to transition ownership fully to the MOH and sustain
effective health system structures. A strategic priority for the government is decentralisation of health
authority management, bringing decision-making and responsibilities closer to the facility level.
 EPHS Delivery: To date the JHNP projects have focused on only two out of the six core components
and delivered with limited, if any, interventions at the community level. The package largely lacked any
nutrition programming, and family planning services were extremely limited. Furthermore, no concerted
effort has been made to date to make sure health facilities are gender sensitive, and child and youth
friendly.
 Health workforce: Absence of personnel, and unqualified/unskilled personnel have been cited in
multiple studies as major barriers to utilisation of public health services. To date, Afmadow has not had
any MOH health facility personnel at all (they were all Save the Children staff). Capacity of health
personnel remains low across all the sites, including refresher training.
 Demand creation: Despite investments under JHNP in the access to and quality of free health services,
without other measures to ensure increased demand for and uptake of services, it has resulted in low
utilisation rates thereby highlighting the need tackle the main barrier to health utilisation. This is

13
 dovetailed with alternative treatment preferences, especially in Adado where preference is for drug
stores/pharmacies when seeking treatment.
 Accountability and ownership: Due to poor quality health services, there are negative attitudes
towards health services, low expectations, a history of bad experiences, and a level of mistrust by the
local populations. In focus group discussions supported by Save the Children, respondents shared that
although they raise issues, concerns and suggestions with the MOH, their voices are not being heard,
further entrenching the disconnect between the health facility and the community.
 Data Quality: As a result of lack of sufficient and accurate data, it has been difficult for NGOs and other
developmental partners to plan accordingly given the capacity of the different regions. UNICEF has
contracted a private organisation to strengthen the data quality across all 3 regions 43

Remaining Gaps
 Health systems are denigrated after conflict and there is no clear pathway/ approach for rebuilding
them44
 M&E a key issue, mainly due to security presenting a challenge to direct monitoring by staff. External
partners capacity for M&E is lacking.45
 Health programs and awareness sessions linking to WASH so as to reduce mortality by communicable
diseases46
 Educative forums on reproduction, safe sex and adolescent health awareness
 Regular women’s reproductive health check-up especially those who have complications during child
labor

Project Design

The Decentralized Service Delivery Model

“The most promising level for pursuing the rationalisation of health service delivery seems the regional, sub-
zonal one. Here, at a pragmatically-decentralised level, information shortages can be addressed, political
dynamics can be understood and taken into account, results can be monitored and informal management
practices harnessed to positive effect, with better chances of success."
- Pavignani E. The Somali healthcare arena: a still incomplete mosaic.

While several initiatives were proposed over the years to establish some form of federal government, each
faltered or failed to garner the necessary support to be implemented. However, an initiative launched in 2012
held greater promise. Since August 2012, the Transitional Federal Charter was replaced with a new federal
constitution, which encompasses principles for decentralization and efforts are made to allow each and every
part of Somalia to join the Federation. The Puntland Charter (1998) and the Somaliland Constitution (2001) are
also important legal frameworks that specify decentralization as the core political, functional, fiscal and
administrative system of governance, with significant devolution of power to the district level for delivery of local
services. However, despite the widespread commitment to decentralization in charters and constitutions, little
progress was made towards implementation. The concept of decentralization was poorly understood and there
was a lack of commitment from line ministries to devolve responsibilities and functions from themselves to local
governments, fearing not only a loss of control and authority, but also the likelihood of staff cuts and smaller
budgets.

Significant progress has been made towards decentralization in recent years. During the course of the National
Development Plan (NDP) 2017-2019, the Federal Government of Somalia (FGS) aims to progressively
decentralize powers to subnational levels. The FGS will support the development of local government at the
district level, with the aim of establishing or strengthening district councils for the 100 or so districts across the
18 regions of Somalia. The NDP recognizes that decentralized fiscal arrangement and ultimately service
delivery is pivotal in building incremental trust between citizens and local government, particularly through basic
service delivery. This contributes to legitimacy since local government is better positioned to facilitate

43 Development of an Embedded EPHS Management Function Implementation Plan for CHANGE Adam Smith Manniondaniels, (2014)
44 Development of an Embedded EPHS Management Function Implementation Plan for CHANGE Adam Smith Manniondaniels, (2014) pg 13
45 Development of an Embedded EPHS Management Function Implementation Plan for CHANGE Adam Smith Manniondaniels, (2014) pg 16
46 Federal Government of Somalia Second Phase Health Sector Strategic Plan (2017) pg. 26

14
reconciliation; as well as adapt common messages of reconciliation to the local context with maximum impact.
In the short to medium term the government will support implementation of the agreed Wadajir Framework on
Local Governance as a natural extension of the Government’s bottom-up approach to political and local security
stabilisation. If local government is neglected during implementation, there is concern that this will put other
political and development processes at risk and create an environment which is unable to deliver sustainable
results. Indeed, local Government, encompassing local administrations and district councils, is the third and
lowest tier of representative government in Somalia and is crucial to building confidence in government
structures because of its close proximity to citizens.

In line with this commitment to decentralised service delivery, this proposed programme will build upon and
adapt Save the Children’s decentralised approach used in the Karkaar Region of Puntland as part of the DFID-
funded CHANGE programme (Community Health and Nutrition through Local Governance and Empowerment)
whereby the decentralized system for the delivery of health care services empowers district authorities, and
communities, while maintaining the support, supervision and accountability role of the regional and national
authorities. The Karkaar Model for Regional Health Strengthening is composed of four core components:

1. Governance: The Karkaar model focuses on strengthening a Regional Health Office (RHO) comprising
of MOH staff which provides leadership, oversight and coordinates all regional health programmes.
Save the Children supports the RHO to set health prioritise, prepare regional health plans, manage
health system inputs of finance, infrastructure, commodities and human resources and health
information. MOH staff also lead capacity building efforts with all cadres of health facility staff. The RHO
is then supported by the Regional Health Board (RHB), which is key to the success of the regional
health system. It promotes community participation in local health service planning, ensuring community
needs are prioritised, and fundraising for local prioritise such as new equipment for health facilities. The
community is also engaged through participation in district health boards and community health
committees which oversee the functioning of the health facility in their location. It also serves as a bridge
between the MOH and community and regularly provides feedback to MOH and implementing partners
on quality and utilization of services.
2. Service delivery: To date Save the Children has focused on the six EPHS core programmes (prioritising
on the maternal and child health components) delivered at community level and 40 fixed facilities from
PHU level, HC, RHC and Gardo Regional Referral Hospital. Each tier refers up to the next level in the
system when encountering cases beyond their remit and for more complex case management. It should
be noted that this was provided under the HCS project, and this was further complemented by another
Family Planning and Post Abortion Care (FPPAC) project. Key achievements included: PENTA3
coverage increased form 20% in 2011 to 100% in 2016; skilled deliveries increased from 4% in 2011 to
61%in 20164; ANC3+ coverage increased from 10% in 2011 to 71% in 201647.
3. Community based interventions: This is then further complemented with other donor funded projects to
implement community level behaviour change through Inter-Personal Communication (IPC) which
brings pregnant and women of childbearing age together in groups facilitated by trained midwives to
learn about healthy practices during pregnancy and early childhood, and Integrated Community Case
Management (ICCM) enables trained CHWs to diagnose and treat the three major killers of children
under-5 (malaria, diarrhoea and pneumonia) in the community, thus bringing critical services to clients
that might otherwise not attend health facilities. The synergy between these different projects was
instrumental in increasing access to services. Indeed, the health service utilisation rate in supported
health facilities increased from 0.14 at the start of the project in 2011 to 0.86 in 2016.
4. Humanitarian Response: The flexibility of the project also enabled timely response to emerging
humanitarian crises. For example, currently Save the Children has scaled up its intervention in Karkaar
to respond to the drought through additional mobile clinics and existing facilities Save the Children was
able was also able to provide health services to cyclone-affected coastal communities in 2013.This was
supported by a strengthened early warning system.

The CHANGE project is now entering its second phase, which will continue to build on the success and lessons
learnt of this approach. The notable achievements already seen by Save the Children in Karkaar region include:
 Implementation and strengthening of a regional health system in Karkaar has enabled decentralization
of MOH functions to the regional and district levels in order to more effectively manage health service
delivery in response to evolving community needs and priorities.

47 CHANGE inception report, March 2017

15
  Strengthening regional, district and facility level MOH staff enabled integration of health programmes
such as maternal, child health, EPI, birth spacing, malaria and HIV, which can be delivered vertically in
other districts by multiple partners, resulting in duplication or gaps in services.
 Supportive supervision by MOH and community structures supported by Save the Children at health
facility, district, regional and state levels have enabled improved service delivery, increased
accountability and greater ownership of the project by the MOH at different levels.
 Community engagement through participation in RHB, DHB and CHCs and facilitated by capacity
building and information sharing have resulted in greater community ownership and increased health
utilization rates. This has been demonstrated through successful community fundraising efforts
enabling improvements to health facilities.
 Community and MOH joint management of health services as well as the built-in flexibility in the HCS
programme also enabled timely emergency responses (such as measles and AWD outbreaks and
cyclone response) to take priority through mobilization of local resources.
 Joint Save the Children/MOH management of the Regional Medical Store (RMS) increased
accountability, efficiency and better resource management with reduced incidence of stock outs and
expired drugs. Save the Children also supported established and capacity building of a health
information unit in the RHO to consolidate data and provide monthly and quarterly feedback to health
facilities enabling them to track their performance and identify priorities for supportive supervision.

This is reflective of other decentralised service delivery model initiatives, such as the UN’s Joint Program on
Local Governance (JPLG). In 2014, a number of decentralization pilots were implemented by JPLG in an
endeavour to implement the decentralization policy and road map. The key achievements of the pilot noted
were: the smooth running of the district operations and functions; sound working relationships between facility
health staff and village health committees due to their frequent engagements and collaborations; utilization of
health services increased at the various health facilities as a result of the improved service delivery mechanisms
installed; increased sense of ownership among the targeted beneficiaries in all those localities where the
medical service delivery had been improved; beneficiaries were willing to contribute to the sustainability of the
improved service; formalized the process of resource allocation in health service delivery; enhanced community
participation in health service delivery model (the Community health Committees access local government
officials to consulting and provide feedback on primary health issues) 48.

The overall design of the project was developed in consultation with the Ministry of Health (MOH). Save the
Children also held a half day consultation with key representatives from the Federal MOH in Nairobi on 16 th
September 2016 during which the Director General and two of the Minister’s advisors provided us with an
overview of the key issues the MOH has faced to date, including challenges with JHNP, and provided
recommendations and strategic direction for EPHS post 2016. Key points raised, that have highly influenced
the design of this project include: Preference for more comprehensive package focusing on the six core program
and four additional programs, even if that means covering less locations; Greater role of the authorities,
including their full involvement in project design, implementation and monitoring, as well as institutional support
and system strengthening towards the six management components; and Political equity and coverage,
including scaling up into newly accessible areas, prioritising areas with high population and considerable gaps
in service delivery. Following the meeting with the Federal MOH, Save the Children also held consultation
meetings with the MOH in Jubaland and Galmudug to ensure their priorities, needs, and gaps were taken into
consideration so we could ensure the project is aligned and contributing to their broader framework and strategy.
It should be noted that the MOH are in the process of finalising the Health Sector Strategic Plan (HSSP) for the
next five years (2017-21) in which there is a chapter dedicated to each federal state that details their strategic
priorities, as well as their priority gaps and needs. Unfortunately, this document was not available in order to
inform the project design, however, it will be reviewed in coordination with the respective state level MOH during
the project inception phase and taken into account in the finalisation and refinement of the package of
interventions.

Project phasing
As flexibility, adaptation and responsiveness are at the core of our project approach, Save the Children is
proposing a multi-phased project to allow for effective and meaningful reflection, feedback and learning to inform
the necessary revisions to the project design - pursuing and adapting activities with promise, and dropping
others - towards the achievement of the project’s outcomes. The project will have 4 core phases, as follows:

48Joint Program for Local Governance and Decentralised Service Delivery: Decentralised Service Delivery Models – Documentation of
Best Practices in Education, Health and Water (January 2017).

16
 YEAR 1 YEAR 2 YEAR 3
Half Year 1 Half Year 2 Half Year 3 Half Year 4 Half Year 5 Half Year 6
1: Inception 2: Pilot 3: Scale-Up 4: Consolidation & Final evaluation

1) Inception phase: The first six months of the project will be primarily dedicated to the inception phase, which
is comprised of three components:
 Project Start Up: This is all the preparation work required to ensure the effective and efficient
management of the project from the beginning, such as recruitment and establishment of the Program
Management Unit (PMU) and recruitment of necessary personnel; consultation with key stakeholders;
finalization of various project documents (see key deliverables below); and project public launch and
internal ‘kick-off’ meeting with key stakeholders.
 Formative Research: Captured in more detail under Outcome 1 of the project, the formative research
is the core component of the inception phase as it is fundamental in designing relevant, effective and
scalable interventions that take into consideration the complexities of the Somali context, particularly
the nuances between the different states and regions. During this component Save the Children will
also undertake any necessary assessments, such as facility infrastructure assessments and MOH
capacity assessments which will inform the details of key project activities.
 Choice and prioritisation of project activities: Based on the findings from the formative research, Save
the Children and other key project stakeholders will finalise the package of interventions to be
implemented during the pilot phase of the project. Whilst Save the Children has proposed a package of
activities to achieve the project outcomes based on our initial situation analysis and previous experience
(see Annex), it is acknowledged that in order to be flexible and responsive, activities may need to be
adapted or refined – or indeed activities removed or new activities added - to ensure they are responsive
to the key barriers, needs and challenges identified in each target location. This will inform the
finalization of key project documents (see key deliverables below). It should be noted that this primarily
applies to the activities under Outcomes 3 and 4 which have a significantly greater element of
innovation. Activities under Outcome 2 (delivery of health services in the target locations) will be initiated
from the project start date and not after the inception phase as these are a standard package of activities
in line with the EPHS, and it is essential that there is no disruption to service delivery as this project is
a continuation of the JHNP project.

Key deliverables of the inception phase are: Terms of Reference for the research, innovation and humanitarian
funds; Terms of Reference (TORs) for project’s management and governance structures; Memoranda of
Understanding (MOUs) with the federal and state MOHs; Pilot Phase detailed budget; Pilot Phase detailed
implementation plan per target location; detailed procurement plan per target location; construction plan per
target location; capacity development training plan per target location; detailed exit strategy with progress
milestones per target location.

2) Pilot Phase: Following the inception phase, the selected package of activities will be implemented at a smaller
scale in select locations for six months. This enables Save the Children to trial and test the different interventions
in the different contexts prior to scale-up. At the end of the pilot phase (end of Year 1), a comprehensive review
will be undertaken by Save the Children, including the collection of feedback from all key stakeholders (MOH,
health facility staff, communities), documentation of lessons learnt and best practices, progress towards project
indicators, analysis of evolving context, risks and assumptions etc. The review will inform any project re-design
that is required to further refine and adapt the project interventions that will be implemented in Year 2 of the
project. At the end of Year 1 all key project documents, namely the detailed implementation plan and detailed
budget, will be reviewed and re-aligned as needed.

3) Scale-Up Phase: Year 2 of the project will see the proposed activities (refined from the pilot phase)
implemented at scale across the target locations. To ensure the project design continues to remain flexible and
responsive to the context and learning, another comprehensive project review will be conducted at end of Year
2 and again the proposed package of interventions will be refined and adapted accordingly to the findings of
the review in preparation for the fourth and final phase of the project.

4) Consolidation Phase: The final phase of the project will be to implement and evaluate an extremely refined
and sophisticated package of activities which the project’s key stakeholders feel present the most relevant and
effective solutions to address the problems identified and achieve results and impact. At the end of Year 3 (end
of the project period) a comprehensive final evaluation will be undertaken, the findings of which will go beyond
just analysing the impact of the project but also generate evidence that can be disseminated widely to other

17
health actors for future replication, and be used to inform wider policy and practice. It is to be noted the basic
lifesaving health services will be provided from the start in parallel with the various phases.

Summary of Objectives & Outcomes

The overall objective of the project is ‘Increased utilization of quality RMNCH services which are accessible,
acceptable, affordable and equitable through provision of EPHS’. This will be achieved through the following
outcomes and intermediate outcomes:

OUTCOME INTERMEDIATE OUTCOMES

1: Evidence base of innovative solutions to inform 1.1 In-depth descriptive analysis of the context
replication and advocacy established conducted to inform project design
1.2 Continuous learning and evaluation of project
approaches conducted to refine project design
1.3 Knowledge uptake and dissemination
undertaken to inform wider policy and practice

2: Essential Package of Health Services, including 2.1 Capacity of health facilities in terms of
nutrition, family planning and reproductive health, infrastructure, equipment and personnel is
delivered to women and children increased
2.2 Delivery of quality health and nutrition services is
provided at facility and community level

3: Health governance and management structures 3.1 Capacity of regional and district level MOH
strengthened structures is increased
3.2 Capacity of community-based structures is
increased
4: Community ownership, accountability and demand 4.1 Communities are empowered to hold duty
for health services enhanced bearers to account and take ownership.
4.2 Knowledge, attitudes and practices for
health, nutrition and hygiene is improved

Intervention Strategy
In order to ensure responsiveness to the changing context and our continuous learning, Save the Children is
not proposing a definitive package of activities to be implemented throughout the course of the project period.
Instead, the strategies below describe the ‘pathways’ we will use towards achieving the outcomes within which
we are able to a greater level of flexibility and adaptation. Each outcome also has an analysis of the key
assumptions, enablers and disablers to achieving the outcome and/or intermediate outcomes in recognition of
the local complexities.

Outcome 1: Evidence base on innovative solutions to inform replication and advocacy established
With the Doing Development Differently approach at the core, this project will have a comprehensive and
embedded research and learning agenda which will not only inform project design throughout the project period,
but also influence wider policy and practice with key health actors in Somalia and beyond. Firstly, an in-depth
analysis of health in the Somalia context will be the focus of the formative research during the inception phase
at the start of the project. Save the Children strongly feels that this is a fundamental component of the project
as the findings will be used to generate recommendations that will be essential to informing program design
and review by ensuring the proposed interventions are relevant, effective and scalable, taking into consideration
the complexities of the Somali context; as well as informing the wider research agenda of the project. The
analysis will try to look at the existing services in the target locations in terms their acceptability, affordability
and equitability, as well as knowledge, attitudes and practices (KAP) in the targeted populations on health,
nutrition, WASH and gender, assessing health seeking behaviour and its determinants, including who utilizes
what types of services and why. The formative research will also provide an opportunity to undertake a more
detailed review of the role of other key actors in the health sector in Somalia, and how their actions are aligned
and/or compliment those of Save the Children, and the major gaps. The research will consist of a literature
review of both Save the Children documentation and all other relevant literature on health and nutrition in
Somalia, including the HSSPs, evaluations and research studies conducted by other actors. If there are robust
evidence of the effectiveness of certain innovations, the project will incorporate those in the initial design. On
the other hand, innovations that have good promise but have not been rigorously tested yet will be the contender

18
for action research. Save the Children will also conduct consultations with key stakeholders, including the MOH
(at Federal, State and District levels); implementing agencies, including UN, NGOs and the private sector;
relevant clusters (including sub-clusters and working groups); academic institutes; and relevant donors. After
the initial literature reviews, any gaps in the evidence will be identified and research questions developed;
appropriate methodologies will be developed, utilising multiple techniques and from a range of informants. The
findings of the analysis will be presented to key project stakeholders via the project Steering Committee and
Technical Working Groups, and will be used to refine and finalise the package of interventions to be
implemented during the pilot phase.

Proper process evaluation is a means of facilitating the iterative process between learning and programme
implementation. Whist this approach will be applied across the full spectrum of project activities to inform the
ongoing refinement and adaptation of interventions; it will focus specifically on innovative approached that have
the potential to revolutionise the health sector in Somalia. Indeed, Save the Children is proposing to implement
a series of activities under the “Innovation Fund” which will be tried and tested in the different target locations
of the project. The findings from the process evaluations will be discussed at district level meetings and during
project review meetings. Possible actions will be determined through these discussions, which can be followed
up subsequently (if applicable). Policy briefs will be prepared including these findings to ensure proper
documentation of the lessons learned. The effectiveness and impact of the pilots in particular will be carefully
monitored and lessons documented which, if successful, can be used for potential scale-up to other project
locations during the project period, as well as used to inform replication by other health actors.

Indeed, a core component of Save the Children’s global theory of change is ‘Be The Voice’, not only to ensure
the voices of children are heard, but also to advocate for better practices and policies to fulfil children’s rights.
Based on this, a strategy for the timely and appropriate sharing to target audiences of specific and generalizable
evidence generated by studies and evaluations will be designed and delivered. Evidence and learning from the
evaluation will be shaped and packaged in a number of different ways to meet the knowledge needs and
preferences of the key audience groups. To most effectively influence policy and practice it is important to
identify and engage with amplifiers and intermediaries - organisations, initiatives, fora and networks - that
convene and connect actors from within and across sectors in Somalia, but also interact beyond the country.
Key communication outputs will consist of: Policy and synthesis briefs, Regular email updates on progress and
findings, Stakeholder meetings, Dissemination workshops and events, Blogs and web news features, Journal
articles, Multimedia products, Social media (Twitter, Facebook, others as appropriate).

Assumptions:
 Key stakeholders are willing to actively contribute towards studies, assessments, surveys,
consultations, including compliance to the research design
 Key stakeholders are receptive to dissemination of findings to maximise knowledge uptake
 Security conditions allow access to the target locations for the timely collection of data
 High capacity of research teams to ensure quality of data collected

Enablers:
 In the HSSP it has specified the creation of research dissemination groups at federal MOH level, and
in some state level MOH there are research units, all of which will be actively engaged to enable the
generation and dissemination of research
 General research capacity building in country office is undertaken, including the strengthening
partnerships with academic institutes.

Disablers:
 Mass population displacement in the target location could lead to high attrition rates between baseline
and midline/endline surveys to maintain quality and relevance of findings.

Outcome 2: Essential Package of Health Services, including nutrition, family planning, and reproductive health,
delivered to women and children
First and foremost, Save the Children will continue to provide the EPHS at the health facilities currently
supported under JHNP to avoid a disruption to services. Indeed, the provision of quality primary healthcare to
vulnerable populations is at the absolute heart of this project and will be implemented immediately and
consistently throughout the project period, in parallel to more innovative and adaptive approaches. Save the
Children will implement the six core programmes of EPHS: 1) Maternal, reproductive and neonatal health; 2)
Child health; 3) Communicable disease surveillance and control, including watsan promotion; 4) First aid and
care of critically ill and injured; 5) Treatment of common illness; and 6) HIV, STIs and TB (although it should be

19
noted that this component will be done in coordination with UNICEF and Global Fund). Each of the six programs
are divided into sub-programs with standardised interventions. The facilities and services provided will be in line
with Save the Children’s Quality Benchmarks for quality assurance. Standards for child and youth-friendliness
and gender-sensitivity will also be integrated into quality assurance measures.

All six core programs will be implemented at three of the four levels of service delivery: primary health unit
(PHU), health centre (HC), referral health centre (RHC); note hospitals will not be supported specifically under
this project. In total, under this project 69 health facilities across 10 districts – 7 RHCs, 18 HCs, 44 PHUs – as
well as 18 mobile units will be supported. Of these, 61 facilities are already being supported under JHNP and
this project will ensure a smooth continuation of service delivery. Following consultations with the various
respective MOH, they have proposed an additional 8 facilities across Afmadow, Kismayo and Adado to reach
more people. MDM will be responsible for the implementation of activities under this result in the 4 facilities in
Bossaso district. The four levels of service are distributed with the aim of improving the coverage of health
services. The primary health unit directly serves communities; health centres serve the catchment populations
of several primary health units; and referral health centres cover the populations of several health centres. The
catchment population of the 69 facilities is 591,926 people. Due to the specific focus of the project on
reproductive, maternal and child health, children, particularly those under 5, and women will be the main direct
beneficiaries, reaching 184,014 women of child bearing age and 237,464 children under 5. Save the Children
will support the referral of complicated cases for secondary care to district level hospitals/Referral health
centers.

In order to improve the quality of health services provided, the targeted health facilities will be supported through
improved physical infrastructure and capacity of the workforce. Some of the health workforce will have already
been supported under the recent JHNP projects and therefore will be targeted for refresher trainings, in addition
to on-the-job mentoring and supportive supervision by Save the Children and the MOH. Where the project is
expanding its efforts to incorporate new health facilities and outreach programs, any new staff will undertake a
full package of training. Save the Children will also provide basic medical equipment (delivery beds, examination
table, blood pressure machines, weight scale and etc.), maternal and reproductive health supplies, nutrition
supplies, malaria testing and treatment supplies, as required. EPI supplies, laboratory supplies, and PMTCT
supplies will be provided in collaboration with UNICEF, Global Fund and GAVI who have the mandate for these.
In recognition of the varying levels of quality and capacity across the different locations, as well as between
facilities, the exact nature of the infrastructure work to be undertaken and the training to be provided will be
determined during the project start-up and inception phase, during which facility level assessments will be
conducted to inform targeted improvement plans.

Furthermore, the health service provision at health facility level will be complemented by community outreach
by mobile medical teams, and the networks of Community Health Workers, specifically benefitting remote and
hard-to-reach locations. CHWs in particular will be trained, equipped, and supervised to enable them provide
quality curative services for common causes of childhood illness such as malaria, pneumonia, and diarrhea in
children under the age of five, and referral of complicated cases along the continuum of care. Furthermore,
through a ‘Humanitarian Contingency Fund’, Save the Children will also have the flexibility to respond to
emerging humanitarian health needs and crises, such as disease outbreaks, in the target locations as well as
other parts of the country as needed.

Finally, to ensure a more comprehensive and integrated package, this project will also include the provision of
nutrition services to treat severe and moderate acute malnutrition among children under 5 and pregnant and
lactating women. Community-level screening and referral for treatment of acute malnutrition will be conducted.
Therapeutic Supplementary Feeding Program (TSFP) will target children U5 and PLW with Moderate Acute
Malnutrition (MAM) and Outpatient Therapeutic Programme (OTP) will target children U5 with Severe Acute
Malnutrition (SAM) without complications. Children with SAM with medical complications will be referred for
inpatient care at the nearest Stabilization Centre.

Assumptions:
 There are no major delays or disruptions to the logistics supply chain. It should be noted that the majority
of the nutrition supplies, such as RUSF, will be secured from UNICEF, although Save the Children has
budgeted for nutrition supplies in case of gaps or supply delays and breakages.
 Security conditions remain stable enough in the target locations to allow continued access to health
facilities by personnel and the beneficiaries.
 There is willingness and commitment by the MOH at state, region and district level to support the
project, including stronger local planning, and joint monitoring and supervision of implementation.

20
Enablers:
 The provision of EPHS under this project is building on the achievements, successes and lessons
learnt from JHNP in the target locations in order to ensure a smooth transition between projects in
order to reduce any disruption to service delivery. This will also benefit from Save the Children’s long
standing acceptance of the communities.
 Launch of the new HSSP for 2017-2021 which can inform and guide state-level priorities and identify
needs and gaps.
 Save the Children is the one of the leading health actors in Somalia, as well as the health cluster co-
coordinator, health NGO forum chair, and the consortium lead for two DFID-funded nutrition and health
consortia, so is well positioned to ensure effective coordination and collaboration with other key
stakeholders at both Nairobi and field level.
 Save the Children, supported by UNICEF and the Global Fund, is currently undertaking a nation-wide
rollout of Integrated Community Case Management (ICCM) in Somalia, developing tools, guidelines
and training curricula for ICCM.

Disablers:
 Any delays to the approval of the proposal and subsequent contracting arrangements could result in a
significant funding gap (as current JHNP project ends on 30th April) leading to breakage in service
delivery.
 The deteriorating drought conditions across Somalia, including in the target locations, has resulted in
increasing levels of malnutrition rates and outbreaks of acute watery diarrhoea and cholera, thereby
dramatically increasing the pressure on health facilities.
 The drought is also driving mass population displacement, either considerably increasing the catchment
population and caseload thereby putting increased pressure on health facility capacity and resources;
or a significant reduction in catchment population would restrict our ability to achieve project targets
and indicators.
 Barriers to demand for and utilisation of health facilities, besides access and quality, for example
preference for private or traditional health actors, gender inequalities, lack of knowledge, cost etc.
Hopefully these would be sufficiently addressed under Outcome 4 to ensure maximum use of the
facilities provided.
 Diminishing and unpredictable funding by donors could lead to termination of services not covered
under this project for e,g Stabilization center in Bossaso and Afmadow district.
 No partners currently supporting CEMONC services in Bosaso. This could break the continuum care
with women having no access to obstetric emergency care.

Outcome 3: Health governance and management structures strengthened

Sustainability is at the core of this project, both at Ministry of Health level and community level. The design of
the project has been done in consultation with the MOH at both federal and state level, thereby ensuring their
overall buy-in to the project, but also to ensure that their strategic priorities, needs and gaps are taken into
account and addressed wherever possible. The project strives towards making a direct contribution to the
objectives and priorities laid out in the health chapter of the NDP and the new HSSP. As outlined at the beginning
of the document, this project will prioritise a decentralized system for the delivery of health care services which
empowers district level MOH authorities, as well as communities, while maintaining the support, supervision
and accountability role of the regional and national authorities.

Save the Children will use the approach used in Karkaar under the CHANGE project whereby it combines both
MOH decentralised structures, such as the regional and district health offices, and community based structures
at the regional and district level through the health boards, and at health facility level through the Community
Health Committees. As the project will be targeting all 7 districts in Bari region, a regional level approach will be
used, as is the case in Karkaar region, supporting the regional level MOH (Regional Health Office) and
establishing a Regional Health Board. However, in Galgadud and Lower Juba, as we are only targeting one and
two districts respectively it is not feasible to have a regional approach, therefore a district level approach will be
used – targeting District Health Offices and District Health Boards. See the structure in the graphic below.

Role of RHO/DHO, RHB/DHB and CEC:

21
 • Part of the MOH decentralised structure
• Provides leadership, oversight and coordinates all district/regional level health programmes
• Sets health prioritises and prepare district/regional level health plans
District/Regional
Health Office
• Manage inputs of finance, infrastructure, commodities and human resources and health information
(DHO/RHO) • Lead capacity building efforts with all cadres of health facility staff.

• Is a community based structure that supports the MOH's DHO/RHO

• Promotes community participation in local health service planning at district level
District/Regional • Ensuring community needs are prioritised at the district level by DHO (fed up from CHMCs)
Health Board • Fundraising for local prioritise such as new equipment for health facilities
(DHB/RHB)

• Is a community based structure at the health facilitiy level that

• Recruit and support to the CHWs at the community level
• Provide a bridge between health facility and community
Community Health • Assess, monitor and track local health status and issues
Committees (CHC) • Mobilizing for action and advocating for improved health services, feeds up to the DHB and DHO

Save the Children will invest financial and technical support into the health governance and management
structures, both at the MOH level and at the community level to increase Somali ownership of the local health
system, as well as increase resilience so government and communities have the physical, behavioural, and
social health to withstand, adapt to, and recover from has adversity and have the ability to mount a robust
response to unforeseen, unpredicted, and unexpected demands and to resume or even continue normal
operations. Recognising that the different state-level MOH involved in the project – Jubaland, Galmudug and
Puntland – have varying levels of capacity, during the inception phase of the project, the activities under this
result area will be aligned and tailored to each state’s chapters within in the HSSP (which are in the process of
being finalised) to ensure maximum relevance and contribution toward their specific state-level plans. Although
capacity building will be tailored to the needs and expectations of each member of the DHMT, the training will
be in line with the EPHS management functions and will generally cover a variety of topics, including HMIS data
management, supportive supervision, advocacy, supply chain management, accountability/financial
management, and disease surveillance.

During the project inception period, Save the Children will sign Memorandum of Understanding (MOU) with
each of the MOH, which will outline the different roles and responsibilities, scope of work and ways of working
together throughout the project period. In order to promote and encourage MOH contribution towards the
project, for example a graduated approach towards staff incentives, training costs, office equipment etc, this will
also be detailed in each MOU with clear milestones and terms. This has already been discussed with the MOH
during consultation during project design, and whilst the commitment is there, it should be noted that for
Galgadud and Lower Juba MOH specifically, due to their limited capacity, their contribution will be minimal at
this stage (maximum of 3%). Their contribution will be negotiated during the inception phase with the support
of the Swedish Embassy and SDC.

Save the Children will also support the capacity building of Community Health Committees to empower them to
undertake the key functions of their role, namely support to community outreach, addressing identified
community issues impacting care, local resource mobilisation to support their facility, and independently monitor
health facility functionality and quality.

Assumptions:
 Political arrangements largely remain unchanged throughout the project period in in order to minimise
disruption to agreements and relationships, as well as minimise MOH staff turnover to solidify gains
towards capacity building.
 The MOH supports and contributed towards an open and transparent process of site selection for
facilities, as well as personnel for capacity building based on identified priorities, needs and gaps.
 There is commitment by the MOH over the course of the project period to support the flexible, adaptive
and responsive nature of the project approach.

22
  There is willingness and commitment by MOH to support the establishment of, and actively engage
with, the community based health board approach, which is a new approach in the Somalia context.

Enablers:
 The approach has strong synergies with similar decentralisation initiatives, including JPLG and
UNICEF’s health decentralisation strategic plan to leverage support and momentum. JPLG in particular
aims to strengthen local governance and enhance decentralized services in all the regions of Somalia. It
helps address the fundamental challenges of weak institutions and resource with unclear roles and
responsibilities and an urgent need to increase the capacity of local government to deliver public
services. The JPLG II is focusing on geographical expansion on where the most urgent needs and
opportunities materialize, including an increased presence in south and central Somalia where a
substantial number of districts have recently become accessible. This includes Adado district and as
such Save the Children will liaise with JPLG partners to coordinate our support to the regional and
district level health offices.
 The MOH in Puntland is already familiar with, and supportive of, the regional collaboration between
RHO and RHBs as it is already being implemented in Karkaar region, and therefore will be supportive
of its roll out in Bari region, and can even provide advice, guidance and encouragement to the MOH in
Galmudug and Jubaland.
 IOM has second an advisor to the MOH in Jubaland (at Kismayo level) to assist in the set of regional
and district level MOH functions. Save the Children will therefore coordinate with IOM in Kismayo to
identify areas for collaboration together to establish this.

Disablers:
 Although there is general consensus and agreement on the decentralised approach, there is a risk that
the MOH may still want to channel support and financial investments to the federal and state level rather
than the district and regional level.
 The capacity of the state-level MOH in Galmudug and Jubaland is relatively low and therefore their
ability to take over the supported facilities at the end of the project period is unlikely, even their ability
to financially contribute to the project, even though a graduated approach, will be minimal.
 Currently there is a weak coordination structure in both Galgaduud and Jubaland.

Outcome 4: Community ownership, accountability and demand for health services enhanced
Community ownership and accountability has re-emerged as a top priority for health systems all over the world,
and particularly Somalia, where governments had failed to provide adequate health services for its citizens.
One approach to strengthening community ownership and accountability is through direct involvement of clients,
users or the general public in health service delivery and quality. Often, despite system strengthening efforts
that equip facilities and train staff, lasting improvements in the quality of services are not achieved. Furthermore,
efforts to improve quality may not consider community concerns and perspectives about service quality;
therefore, improvement efforts can fail to meet the needs of the community. This exacerbates a social distance/
culture gap between service providers and the communities they serve. This gap can affect relations between
clients and providers. Save the Children will therefore pilot innovative approaches that improve the quality and
accessibility of services with community involvement in defining, implementing, and monitoring
the quality improvement process, in acknowledgement that solutions and remedies for service quality issues
often rest within the community, and that the responsibility for better health goes beyond the health system as
individuals and communities to some extent control their own health.

This will be further complemented by a variety of behaviour change and demand creation initiatives in the target
locations, including innovative approaches, as the role of knowledge cannot be ignored when examining
motivations and barriers to health seeking behaviour. Without knowledge or previous exposure, the benefits of
essential services cannot be internalised and prioritised by a community. Save the Children will utilise high
levels of community mobilization through Community Health Workers, which act as a linkage between the
community and the health facilities; and being trusted community members this help to ease concerns that may
arise around health centre utilization. This will be further supported through other mass communication
initiatives, as well as testing innovative adaptation to standard approaches, such as support groups, to explore
avenues for increased effectiveness and impact. Save the Children also hopes to build the resilience of
individuals, community based groups and committees, and the community at large to adjust its functioning prior
to, during, or following changes and disturbances, and to implement positive adaptive behaviours matched to
the immediate situation, while enduring minimal stress.

23
Finally, until utilisation of public health facilities significantly increases, private health providers, particularly
pharmacies/drug stores will likely continue to be the first preference for treatment for segments of the population.
Specifically targeting and positively engaging the private sector in Somalia is still relatively at the early stages,
but under this project Save the Children will explore initiatives and approaches to strengthen positive
relationships built on foundations of mutual respect and recognising the role of both formal and informal
healthcare providers in the Somalia context.

Assumptions:
 Security conditions remain stable to allow continued access to target communities as behaviour change
requires continued follow-up to maintain momentum and gains made; progress could be halted or
reversed if it is stopped for an extended period of time.
 There is willingness, commitment and ability of the target communities to participate in the activities
proposed activities.
 There is willingness and openness by the authorities and service providers to be receptive to
constructive feedback from communities.
 There is willingness by pharmacies and private healthcare providers to engage in opportunities to
strengthen the relationship with the public sector.

Enablers:
 This project can complement a DFID-funded health demand creation project led by PSI, of which Save
the Children will be an implementing partner. The two projects can have both geographic
complementarities to assess the impact of different initiatives in different demographics, as well as
share lessons learnt and best practices with each other to maximise results.
 A SDC-funded project that is promoting the self-regulation and quality assurance of private healthcare
providers, especially pharmacies and drug stores. As Save the Children, under this project, will
undertake a mapping of pharmacies to encourage coordination by the district level MOH and foster
informal referral mechanisms to health facilities, it will be interesting to facilitate a connection between
the two projects if possible to leverage impact.
 In October 2016, Save the Children has initiated a four year DFID-funded ‘Challenging Harmful
Attitudes and Norms for Gender Equality and Empowerment in Somalia’ (CHANGES) project. The first
year of the project (2017) will be dedicated to design and inception, an essential exploratory phase
during which formative research will be undertaken to inform programme design, and allow for the
adaptation and piloting of new models, after which the proposed project 2018-2019 will seek to
challenge harmful social norms including FGM and CEFM and to increase women’s social and
economic empowerment through interventions at the individual, household, community and societal
levels. This project will be implemented in Adado district (among others) and Save the Children will
ensure synergies between the two projects in recognition of the gender dynamics in health and nutrition
practices and health seeking behaviours.

Disablers:
 Save the Children sees this outcome as having the greatest scope for creativity and innovation in order
to address key, and largely unsolved, issues and challenges related to community ownership,
accountability, and utilisation of health care services in Somalia. While this presents an exciting
opportunity it also presents a barrier to ensuring we will achieve the outcomes.
 There is a lack of social and public accountability systems across the three targeted regions, as is the
case across Somalia, and therefore this is an approach that may not be welcomed by duty bearers and
local authorities if they do not full understand of appreciate the value it can have.
 There is the risk of courtesy bias which is the tendency for respondents to understate any dissatisfaction
because they don't want to offend the organization seeking their opinion. This is something Save the
Children faces already in our standard project complaint and accountability mechanisms. Extra efforts
will need to be taken in community sensitisation before initiating social accountability approaches.

Monitoring & Evaluation

In 2015 Save the Children rolled out a new Monitoring, Evaluation, Accountability and Learning (MEAL)
approach that moves beyond a basic M&E system to ensure that stakeholder opinions are actively sought;
activities are assessed against quality benchmarks; programme improvement actions are planned and
completed and findings feedback into decision making. As part of the proposal development stage we have
developed a list of Outcome Indicators which have been formulated and include specific milestones for the

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project period. For the outcome and impact level, as far as possible reference has been made to the indicators
and definitions that government uses to measure progress. Both quantitative sources and qualitative data
sources have been considered in this process. MEAL is streamlined throughout the project cycle, and in addition
to the activities under Outcome 1, the MEAL will be responsible for:

 Monitoring performance: Based on the project’s performance indicators, data collection will be done
following an agreed plan which will stipulate data that has to be collected, the best sources of the data, the
frequency of collecting the data collection and the tools to be used. The programme MEAL manager will
lead the process of developing common tools that will be used to ensure coherent and unified data
collection. As far as possible, mobile phones technology will be used across the programme for cost
effective data collection and analysis. The programme will seek to involve community members in
monitoring the progress on set targets as well as factors that might hinder achievement of expected results
especially in regard to health service provision. An analysis of key performance indicators and other findings
from monitoring will be shared with the local partners and discussed in relevant review meetings to inform
decision-making and agree on improvement actions. The information generated from performance tracking
(through quality benchmarks or action trackers) are intended for localised actions. They can be as specific
as identifying individual CHW or professional for capacity building or training, specific facility requiring
supports to meet standards or communities to be better informed about the programme.
 Learning: The MEAL system will produce information that feed into the process evaluation, action research
and impact evaluations. Appropriate review meetings will be conducted at field level and Nairobi level to
facilitate critical reflection of progress and learning between organizations on what is working well and what
is not working well. Discussion of monitoring and research findings at these meetings will foster culture of
knowledge based programming. MEAL also provides an avenue of documenting to capture the tacit
experiential knowledge of the implementation teams. Annual reviews will be undertaken for a more in-depth
review of the project’s performance with a view to draw lessons and make necessary programme
adjustments for the remaining project period. Success stories, innovations and best practices will be
documented and shared within the wider community of actors in the health sector.
 Quality Assurance. The programme will monitor the quality of interventions/activities to ensure that
standards for quality are met and that there is value for money. Specifically quality benchmarks will be
developed for training activities to ensure the same standard of defined quality is applied in all
implementation areas. The benchmarks will define details on specific training manuals to be used, the
number of days and the number of participants for given trainings and the number of participants for given
trainings. Quality benchmarks for starting and supporting mother support groups will be developed and
used in all programme areas. The programme will also put in place a mechanism for collecting beneficiary
feedback on the quality of the interventions supported by the programme. The mechanism will include
beneficiary satisfaction interviews where beneficiaries will express their level of satisfaction with their
engagement in different activities, beneficiary selection and issues of gender. This survey will be built on a
digital platform for cost effectiveness in data collection.

Coordination
Due to our long operational history and broad geographical coverage, Save the Children has established
positive working relationships with key stakeholders, including national government, local authorities, donors,
international and local NGOs, as well as the trust and acceptance of the communities themselves. Save the
Children is highly active in national and regional coordination mechanisms in Somalia and Nairobi. The
organisation regularly participates in Cluster coordination - Protection, WASH, Food security, Education, Health,
and Nutrition - and is the Cluster Co-Coordinator for the Health and Education clusters, and the Chair for the
Health NGO forum. This means Save the Children is proactively sharing information with other health agencies;
assisting in jointly assessing/analysing information; prioritizing in-country interventions and locations to fill gaps
and avoid the duplication of efforts; monitoring the humanitarian situation and the sector response; adapting/re-
planning as necessary; mobilizing resources; and advocating for humanitarian action. Save the Children
represents INGOs in the CHF board that directs the Clusters, sets priorities for funding and decide to allocated
funds to various sectors.

Save the Children recognised that EPHS post-2016, following the closing of JHNP in December 2016, will likely
result in a new coordination platform between donors and/or NGOs and Save the Children will of course be
actively involved in the setting up of this process. With regards to the specific locations under this project –
Adado and Afmadow – Save the Children aims to establish a district level Community of Practice with all health
actors – government, INGO and CSO. This platform will go beyond information sharing (who does what and
where) and coordination of activities, but focuses more on sharing experiences, learnings and best practices to

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promote a more collaborative partnership between health actors at the district level. This can also provide a
forum through which to undertake joint advocacy, joint campaigns and joint positioning with the MOH, donors
and the wider health community, and collectively be the voice of the communities we serve.

In addition, this project will build on strategic partnerships of Save the Children. We have a three year (2016-
2018) strategic agreement with WFP which seeks to widen the potential of our joint work beyond project or
funding relationships into advocacy, campaigns, innovation, research, and gender-sensitive programming. As
part of this Save the Children will partner with WFP to explore options to use biometric registration of health and
nutrition facility users, as well as beneficiaries from other projects, through the SCOPE system in the selected
locations. The benefits of this would be two-fold: 1) Cross referencing and analysis of biometric and health
facility data will allow for real-time trend analysis, and highlight areas and groups which are underserved or
excluded; and 2) By also registering beneficiaries in our other projects (WASH, protection, education) in the
target districts, we will be able to identify which beneficiaries benefit from multiple thematic responses and
therefore better analyse and evaluate the impact of integrated programming in addressing the multi-dimensional
needs of women and children in Somalia. Save the Children also has a three year (2016-2018) strategic
partnership with UNICEF under which we have committed to work more closely together to effectively tackle
protection, development and survival issues affecting children in Somalia and to support enhance collaboration
and synergies between our two organisations.

In order to ensure this project maximises its contribution to the wider health sector in Somalia, a stakeholder
mapping will be conducted during the inception phase and specific engagement and coordination plans put in
place where relevant. For example, the Swedish Embassy, along with the Finland Embassy, will also be
financially contributing toward UNFPA’s new strategic plan for Somalia, under which they will be prioritising the
provision of CEmONC services. As such, Save the Children have held a consultation with UNFPA and the
following points were agreed: 1) They will be procuring family planning commodities, but we should continue to
make our requests via the MOH; 2) As we are also planning to provide CEMONC services in Bossaso (via
MDM), Dhobley and Adado under this project, UNFPA will factor this into their service mapping to avoid overlap
and ensure community coverage; 3) UNFPA support midwifery schools in Bari, Dhusamareb and Kismayo and
have asked us to accept students in health facilities close to these, as well as to support their efforts in
coordination in ensuring all midwives are certified and registers. Save the Children and UNFPA have agreed to
have regular meetings to further develop and enhance our coordination together, and Save the Children hopes
to extend this level of bi-lateral coordination with other key actors, particularly those leading initiatives outlined
under ‘enablers’ above, with the support of the Swedish Embassy, SDC and the MOH. There is certainly
potential to use the project Steering Committee as a forum for such coordination initiatives.

Cross Cutting Themes

Do No Harm / Conflict sensitivity
Save the Children implements do-no-harm principle in its entire humanitarian and development work. This is
ensured through the quality benchmarks that have been developed for all the specific activities carried out by
the organisation. There are a few main areas that Save the Children has identified under this project that, if not
addressed appropriately could lead to harm of our beneficiaries. These include:
 Clan dynamics: The target locations are largely homogenous, however, clan identities are not static
and fixed, but are shaped and manipulated according to changing situations. They are not inherently
conflictual, but rather clan identities can be manipulated purposefully to acquire control over resources
and power. Although the target locations are largely homogenous, Save the Children recognized that
clan dynamics can play at key role in the success of a project, particularly ensuring that minority ethnic
groups have equal access to health and nutrition services provided. Save the Children promotes
impartiality at the heart of its work, and this is reflected in our Code of Conduct signed by Save the
Children staff, as well as MOH health facility personnel, and it is included in MOUs with the MOH and
community groups. Health and nutrition services at both the facility and community level are provided
on based need and vulnerability criteria, regardless of religion, socio-economic status, sex or clan.
Under the upcoming DFID-funded SNaP project, as part of the formative research Save the Children
will undertake conflict sensitivity analysis, including clan dynamics, to better inform our understanding
of the context and this will feed into our deeper understanding in the target locations. Furthermore,
any issues throughout the project period can be reported through our complaints and feedback
mechanism, and potentially through the PDQ model also.
 IDP vs host community: Particularly in Afmadow, where there is a large IDP population living alongside
the already vulnerable host population could result in competition and conflict over already-limited

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 resources and overstretched services and infrastructures. This could be exacerbated as the
repatriation process from Dadaab continues and we see more returnees transiting through or settling
in Afmadow, particularly Dhobley. The health and nutrition services are provided to the entire
catchment population, including host, IDP and returnee populations, and as such are provided to those
in need and based on critical vulnerability criteria, regardless of their status. Community groups and
community-based structures will include representatives from across the target community, including
IDPs and returnees so they unique needs and challenges are incorporated and addressed.
 Gender mainstreaming: This project has a strong gender mainstreaming approach which is in line with
Save the Children’s Gender Equality principles and policy. In the Somalia context, women and girls
are considered legal minors and do not traditionally have a place in public fora, and have extremely
limited decision making power over their bodies and lives. As such, specific efforts encouraging equal
and meaningful participation of women in community-based groups (DHB, PDQ, and CHC) could
create tensions within the community and families. It is therefore essential that Save the Children
undertakes comprehensive sensitisation of men and women in the community to promote the active
engagement of women, and supports women in these groups to ensure their voices are heard. The
Somalia Country Office has two gender focal points that can provide support to the field teams to
ensure gender is mainstreamed throughout, and this will be supported by a gender equality action
plan for the project (which is a tool we have introduced recently).
 Community empowerment: In focus group discussions supported by Save the Children, respondents
shared that although they raise issues, concerns and suggestions with the MOH about the health
facilities they use, they are not being acknowledged or considered. Indeed, in the Somalia context
there is a social distance/culture gap between service providers and the communities they serve and
this gap can affect relations between clients and providers. Under this project Save the Children
intends to bridge this gap through the PDQ social accountability model. However, it is recognized that
this is a new approach in Somalia and empowering communities could result in conflict with service
providers and local authorities. It is for this reason that the first step of the PDQ model is building
support, whereby obtaining commitment for participation from both the community, such as community
leaders and other groups that may potentially be mobilized to represent the community voice in quality
improvement; as well as seeking the approval and support of the decision makers at the local level
and district levels, and maybe even the regional level if required to ensure buy in on all sides.
 Child safeguarding: Children who come into contact with Save the Children as a result of our activities
must be safeguarded to the maximum possible extent from deliberate or inadvertent actions and
failings that place them at risk of child abuse, sexual exploitation, injury and any other harm. This
responsibility falls upon all of our staff and representatives and is reflected across many policies. This
duty of care is enshrined in our Child Safeguarding Policy. All staff are required to undertake child
safeguarding training as part of their induction process and are required to sign and adhere to the child
safeguarding policy. The Policy requires that everyone associated with the organisation is aware of
their obligations and responds appropriately to issues of child abuse and the sexual exploitation of
children. In this way we make Save the Children safe for children and by creating a child safe
organisation; we honour their rights and our aspirations.

Environment
Key principle of SC’s work is mainstreaming environmental considerations into all aspects of project design and
implementation. Globally, SC works in the area of Climate Change Adaptation’ through which SC addresses
environmental needs through direct engagement and planning with communities, and builds on the resilience
of community members. The environmental impact of the proposed interventions will be fully considered prior
to any construction works (in particular regarding the clinic and latrines) and the sustainability of water resources
will go through a programmatic consideration. SC will adopt basic checklists that include environmental criteria
to verify that construction activities meet standards and are not hazardous to the environment, and thereby also
children. At all health facilities we follow MOH procedures and guidelines for the correct disposal of medical
waste. All latrines constructed by SC will follow Sphere standards to ensure minimal risk to the surrounding
environment in that pit latrines and soakaways are at least 30 metres from any groundwater source and the
bottom of any latrine is at least 1.5 metres above the water table. Drainage or spillage from defecation systems
must not run towards any surface water source or shallow groundwater source. Where there is a
rehabilitation/construction plan, an environmental impact assessment will be conducted before any construction
work takes place, the findings of which will feed into construction plans. Where possible, during rehabilitation
work, Save the Children will promote the recycling of materials wherever possible, and the use of solar or energy
saving/efficient equipment, for example health facilities will be will be fitted with Solar panels for lighting and
equipment sterilization, purposes and only energy saving lumps will be utilized.

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Stakeholder Participation & Accountability
In preparation for this project, Save the Children consulted with key stakeholders, including community
members, health facility personnel, CHC and the Ministry of Health at both Federal and State level. Save the
Children conducted a rapid needs assessment to generate basic descriptive statistics of health service access
and utilization. A survey a with structured questionnaire was conducted between 6th and 12th September 2016
in 22 communities from 7 districts (including Afmadow and Adado). The survey covered 258 households with
over 1,500 members and 429 under five children. The assessment also included key informant interviews with
health facility staff and health committee members. The survey enabled us to gather information about the key
barriers in access to health services, and gaps in health service provision and quality. With regards to their
ongoing engagement and participation throughout the project cycle, Save the Children will continue to engage
with key stakeholders through a variety of mechanisms. The MOH at both federal, state and district level will
play a key role, as both a beneficiary of capacity building efforts, but also in terms of wider sector coordination,
monitoring and supportive supervision. They will also be heavily engaged in the planning and design of the
research actions, including the dissemination and uptake of findings.

While the project will seek to strengthen the capacity of community members to demand for better services,
particularly through the strengthening of Social Accountability groups, CHCs, and DHBs, the programme will
also work on being accountable to beneficiaries, including children, and all other stakeholders. Accountability
to beneficiaries will focus on extensive sharing of information about this programme in terms of what it is aimed
at achieving, avenues for community participation and mechanisms for beneficiaries to give feedback or log
complaints upon dissatisfaction. This programme proposes a number of activities for community members to
participate; this in itself will facilitate accountability beneficiaries. In terms of participation, beneficiaries are given
information on activities or processes in which they can participate. Some of the activities where beneficiaries,
including children and youth, participate include identification of community needs and priorities, selection of
beneficiaries, monitoring and evaluation of programmes. Specific attention to mechanisms for child participation
is created and Save the Children is continuously exploring opportunities for growing children’s participation in
the context of Somalia, for example child-accessible and friendly suggestion boxes and children-friendly and
appropriate focus group discussions. The programme will establish community preferred mechanisms for giving
feedback during the different formative research activities. Based on the findings, appropriate feedback and
complaints mechanisms will be put in place to gather feedback that will be used to improve the programme.

Risk Management & Mitigation

Given the significant long-term operational experience of Save the Children in implementing programs in
Somalia, we are confident that we have a strong and comprehensive understanding of the context and operating
in a fluid and volatile environment. Risk management is a Save the Children global priority whereby every
country office’s risk management plan addresses seven mandatory risks (child safeguarding, resources to
prohibited groups, fraud, logistical capacity, HR capacity, security conditions and donor requirements) in
addition to context-specific risk. Save the Children Somalia has a comprehensive Risk Management Plan in
place (see Annex), through which designated members of the Senior Management Team continually monitor,
review and report against on a quarterly basis. In addition, below is a project-specific risk assessment which
assesses risks not only associated with the security, political and environmental context, but also risks
associated with programming, partners, HR, logistics, capacity, finance, compliance etc. Save the Children has
also undertaken a risk analysis for this project based on the target locations and types of interventions proposed,
and mitigation measures put in place. See Annex. The risk matrix will be reviewed during the internal project
kick off meeting by all project staff, including partners, and it will be reviewed on a regular basis during project
reviews, led by the project management team, to identify any changes to the risk, the impact or likelihood rating,
and any revisions that need to be made to the mitigation measures. These recommendations will be escalated
to the steering committee for consideration and decision making. The main risks are outlined below, but see
Annex E for detailed project risk assessment.

RISK MITIGATION MEASURES

Safety & Security: Political instability, law Save the Children’s safety & security manual outlines
enforcement is significantly weak and sub clan procedures for managing an emergency or incident.
traditional customary law is active and more This is complemented by a country specific safety
applicable. AS has continued to carry out a number and security management plan. We have a fully-
of hit and run attacks and attempted several complex fledged safety and security department centrally led
attacks. ISIS affiliation recently has recently added to by the Head of Safety & Security who oversees a
the insecurity and sub clan conflict remains a team of dedicated area security managers based in
constant source of insecurity. Al Shabab activities each area office. Weekly staff meetings are held at

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against Somalia National forces and AMISOM both Nairobi and field level which include updating all
continue to be reported. Security operations and staff about security incidents, how these impact our
movement restrictions following attacks are likely to programmes and staff, and the decisions/actions
temporarily disrupt programme activities. Attacks, taken. The safety and security team work closely with
ambushes and hostage taking against staff and the regional security forums as well national security
assets. bodies such as the NSP (NGO security programme),
UNDSS (UN department for safety and security) and
the local security authorities to access security
information for early warning and early action. All staff
are required to complete Personal Safety & Security
training course as part of their induction; receive
Basic First Aid training at least twice a year, and
Psychological First Aid training at least once a year;
and newly recruited staff must participate in a
Resilience Profiling Training prior to starting their
mission. Traumatic and Stress Management Training
is required for Managers running programmes so
they are able to support their junior staff. All staff,
both national and expat, are provided with
comprehensive health insurance and personal
accident and disability insurance.
Environmental: All of the proposed project locations Save the Children’s field teams closely monitor the
are currently experiencing deteriorating drought context in the target locations, including liaising with
conditions, which are projected to worsen in the other key stakeholders to gather and share
coming months resulting in population displacement. information. If necessary, Save the Children will
There areas are also prone to outbreaks of undertake a rapid needs assessment to identify the
communicable diseases, particularly cholera/AWD, emerging needs and gaps in order to analyse how it
typhoid, dengue and malaria, which could be could impact on the project’s implementation. Save
exacerbated by drought conditions, worsening the the Children has also included a contingency fund for
health and nutrition status of the population. humanitarian response as part of this project which
will enable us to respond to crises, including
displacements, outbreaks etc without compromising
the other output and outcomes of the overall project.
In the event that a change in the situation has a
significant negative impact on the project, it will be
escalated by the PMU to the steering committee to
identify solutions.
Social: Behaviour change activities Work closely with and build capacity of local actors,
challenge/promote the change of deeply opinion makers and key influencers, such as
engrained/traditional social norms, especially community/religious leaders, community health
addressing issues around health/nutrition behaviours workers to influence behaviour change. Furthermore,
and practices, gender equality and social we are working in areas where we already have a
accountability. strong presence, particularly in providing health care
services.
Logistics: These may vary depending on the Procurement and supply chain planning to
location, but may include lengthy lead times, preposition stock and ensure that medical
expiration of drugs, unforeseen high costs of /pharmaceutical supplies are delivered on time and in
procurement and freight, unpredictable security quality. Framework Agreements (FWA) are in place
threats to assets. with key suppliers All our warehouses have a guard
gate, adequate lighting around the perimeter, use of
locks on all windows and doors, perimeter fencing,
and cargo storage procedures that help keep the
location and goods secure. SCI also monitor the use
of drugs at the facility level as part of its routine
supervision activities.
Child-safeguarding (CSG): As this project focuses SCI has strong CSG reporting mechanisms in place.
on child health and nutrition, children will be the direct All staff are required to complete CSG training as part
beneficiaries of the project and will be in direct of induction and refresher training, as are all partners
contact with SCI staff, partners, MOH staff, as well as and contractors. There is a CSG champion in each
area office to monitor and provide support as needed.

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 contractors and community members/volunteers Project specific CSG risks and mitigation measures
which increases their exposure to risks. are identified during project kick off and reviewed
during regular review meetings. All staff are vetted
before recruitment.
Fraud, corruption, diversion of aid: SCI staff or Beneficiaries will be given OTP cards for easy
partners paying/offering/requesting/receiving a bribe; identification at the sites and to prevent fraud in the
Nepotisms; embezzlement; collusion; abuse of distribution of nutrition and health supplies. All
position of trust; risk of beneficiaries being coerced to distributions of supplies are recorded in the OTP
handover commodities and/or pay for services register book to ensure that supplies are adequately
received by gatekeepers; fraud related to tracked and supply movement is monitored from the
invoicing/payroll/procurement/expenses etc. warehouses to the OTP sites. Complaint Response
and Accountability Mechanism: with beneficiaries
being sensitized on beneficiary accountability
standards. Conduct regular internal and compliance
audits. Provision of training to all new staff and
partners (including refresher training) on the types of
fraud, bribery and corruption, the signs, and how to
report them. All staff and partners must sign the
fraud, bribery and corruption policy and
whistleblowing policy.

Exit Strategy
Save the Children Somalia hopes to eventually exit from Somalia/Somaliland at some point but certainly not in
the near future. Somalia’s progress on the SDGs to a large extent will inform how long Save the Children will
continue operations in the country. Current strategy is to grow, increase reach especially to the most deprived
children and invest in programme quality and system building at central and local levels. These are important
elements to sustaining any gains in fulfilling children’s rights. For the Somalia Country Office, Exit does not
mean closing projects or withdrawing funds. It is a process that ensures that the gains made in improving
children’s lives through our operations are protected directly or indirectly. Sustainability is an important subject
conjured repeatedly throughout delivery of emergency and development programmes.

Save the Children considers Exit Strategy as a Sustainability/Continuity plan for a programme/project’s impact
or gains regardless of timing and location. Save the Children is conscious of the fact that long-term sustainability
of programmes is dependent on existence of strong government of Somalia/Somaliland with sufficient capacity
to serve its peoples. Given the current situation in the country, this is not foreseeable in the near future.
However, the focus of Save the Children’s work in Somalia/Somaliland has been on building local capacity
through partnerships with national civil society organisations, working through the existing government
institutions, supporting decentralized service delivery and involvement of children and local communities in
project implementation and monitoring. Working through existing local structures ensures that local capacity
development is engrained in service delivery programmes and local service providers are therefore, however
minimal, able to continue supporting service delivery after the completion of Save the Children interventions.
See Annex – Save the Children Somalia Exist Strategy Guide.

For this project, Save the Children will develop a detailed exit strategy during the project inception phase. Due
to the contextual variations between the target locations, an exit strategy will be developed for each target region
– Puntland, Galmudug and Jubaland. The exit strategy will be reviewed regularly throughout the project period
to monitor progress towards milestones, as well as to strengthen and/or make adjustments. Save the Children
will utilise a combination of the following three approaches:
1) Phasing down – a gradual reduction of program activities, for example training and capacity building of
MOH and health facility staff.
2) Phasing out – withdrawal of involvement without handing it over to another institution for continued
implementation, for example the research studies.
3) Phasing over – program activities are transferred to local institutions or communities, for example
delivery of health services.

While the details of the exit strategy will be established as part of the inception phase deliverables, the key
concerted initiatives in the project design that are already contributing towards our exit include:

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  The strengthening of regional and district level MOH through comprehensive capacity building
interventions, as well as support to MOH infrastructure. This support will enable the district level MOH
to provide leadership, oversight and coordination to all health programmes.
 A variety of behaviour change initiatives will be undertaken in the target locations to improve health,
nutrition and hygiene practices, as well as addressing barrier to positive health seeking behaviours to
ultimately increase community demand for and utilisation of the health services available.
 Save the Children will support the RHO and DHOs throughout the project period to set health priorities,
prepare health plans, manage health system inputs of finance, infrastructure, commodities and human
resources and health information which will benefit the sector as a whole.
 The project will support capacity building of healthcare providers, including doctors, nurses, midwives,
lab technicians, as well as community health workers. By building the capacity of health facility staff,
we can ensure the provision of high quality health services beyond the life of the project.
 It is proven that social accountability mechanisms increase community ownership of the health services,
and as such communities are more likely to invest their own resources, be it in the form of materials,
labour or money, in order to contribute to the improvement of services. Community Health Committees
and the RHBs/DHBs will be trained on local resource mobilisation towards successful community
fundraising efforts enabling improvements to health facilities and support towards staff incentives,
thereby working towards the financial sustainability of the project.
 During the project inception period, Save the Children will sign Memorandum of Understanding (MOU)
with each of the MOH which will outline the different roles and responsibilities, scope of work and ways
of working together throughout the project period. In order to promote and encourage MOH contribution
towards the project, for example a graduated approach towards staff incentives, training costs, office
equipment etc, this will also be detailed in each MOU with clear milestones and terms. This has already
been discussed with the MOH during consultation during project design, and whilst the commitment is
there, it should be noted that for Galgadud and Lower Juba MOH specifically, due to their limited
capacity, their contribution will be minimal at this stage (maximum of 3%).
 To combat the effect of recurrent shocks and stresses, Save the Children will invest support to increase
resilience of government, service providers and communities, so they have the physical, behavioural,
and social health to withstand, adapt to, and recover from adversity, and have the ability to mount a
robust response to unforeseen demands as well as resume, or even continue, normal operations.

Project Governance & Management Structure

Save the Children has extensive in managing large and strategic projects, including in consortia, both as a lead
and as an implementing partner. For example, Save the Children is currently the consortium lead for the EU-
funded Education for Empowerment program in Somaliland (US$14m over 3 years); DFID-funded
Strengthening Nutrition in Somalia (SNS) program (US$14m over 2 years) and DFID and Norwegian Embassy-
funded Challenging Harmful Attitudes and Norms towards Gender Equality in Somalia (CHANGES) program
(US$9m over 4 years). Based on this experience and the lessons learnt, Save the Children proposes the
following management and governance arrangements for the project:

Governance: Steering Committee

Management: Project Management Unit

Coordination: Technical Working Groups

Steering Committee: The Steering Committee is a forum for key project stakeholders, composed of senior
representatives from the Swedish Embassy and SDC, and Minister and/or Director General from MOH, as well
as senior representatives (typically the Country Director) from Save the Children and partner MDM. The Project
Manager will attend ex-officio. The Terms of Reference for the Steering Committee will be established and
agreed by all members during the project star-up and inception phase. Based on our previous experience, the

31
Steering Committee meet on a quarterly basis at the start of the project and will typically reduce to bi-annual
meetings during program implementation, if appropriate. The Steering Committee will be responsible for: Setting
and monitoring the strategic direction for the project; Undertaking joint periodic project reviews; Review and
approval of recommendations from CMU and TWGs; Validation of research and evaluation findings; and
Approval of any significant changes to the program design, budget and governance/management structure;
Information sharing and joint analysis of changes to the context and operating environment. Although largely a
forum for the project specific stakeholders, it can also be a forum to invite external stakeholders to discuss
issues of shared interest to boost collaboration and coordination between programmes.

Project Management Unit (PMU): The PMU will consist of a dedicate Project Manager (with technical expertise
in health), a dedicated Awards & Finance Coordinator, and a dedicated Monitoring, Evaluation and Research
Manager. The PMU will be responsible for: Managing the relationship with the donors (Swedish Embassy and
SDC); Administering partner sub-grant agreements with MDM; Ensuring donor compliance; Development and
submission of all contractually required reports; Tracking success of the programme and escalating issues to
the SC; Managing government engagement; Coordinating and information sharing with other stakeholders;
Overseeing programmatic audits and reviews. The PMU will provide management oversight of the TWGs and
report to the SC.

In terms of programmatic oversight, at field level, there is an experienced health program team led by a Program
Manager. Furthermore, the Country Office team is supported by technical experts from the East Africa regional
office and HQ in the UK and Sweden who provide technical support and oversight and bring both regional and
global experience, lessons learnt, best practices, as well as technical tools, guides, strategies and approaches
to the project. This is further enhanced by our long-established area office in Mogadishu with a strong
management and financial team in place supporting the field offices in Adaado and Afmadow (based in Dhobley
town), to facilitate the hands-on support in implementing projects. With regards to technical oversight, since the
merger with Merlin in 2014, Save the Children has become one of the largest health actors in Somalia, and has
been the largest implementing partner of JHNP as well as the DFID-funded CHANGE project. As such, Save
the Children has strong professionals and experts in health, both in the Nairobi and area offices in Somalia,
with a profound knowledge of the broader context and the health system in Somalia. Under the Director of
Program Development & Quality, there is a dedicated Head of Health & Nutrition that leads the overall strategic
direction of our quality health programs across Somalia and provides technical support to ensure quality
program development and implementation. Under the Head of Health & Nutrition, there is a field based Senior
Health Technical Specialist (SHTS) who supports quality program implementation at field level and the
programme implementation in each Zone is managed by experienced Heath Programme Managers based in
the field. To facilitate a rapid decision making process the Health Programme Managers are made to report to
the Area Representative, with only a dotted reporting line with the SHST. In addition to the rich in country
expertise, the member office (SCS) will provide technical advice and quality assurance to the in country team.

The Country office’s Award Management function, overseen by the Awards Director, provides operational
support and oversight throughout the life cycle of an award and as such will connect and coordinate roles and
processes during the management of an award and play a leading role in ensuring the award is well managed
and donor compliance requirements are met. This is strongly supported by the Award Management teams at
the Members level – in this case SC Sweden and SC Switzerland – for quality assurance and compliance. All
Save the Children programs are required to comply with the procedures presented in the Award Management
Manual. The Award Management team will work closely with other staff to effectively support program quality,
donor compliance and accountability to all stakeholders. All awards are managed through Save the Children’s
Award Management System (AMS). The Somalia Country Office has a dedicated Audit and Risk Manager to
ensure a complete audit trail will be kept for any cost incurred under the grant with proper documentation for
auditing and compliance checks. KPMG LLP are our global auditors who do the SCI audits. For the Somalia
office we have Framework agreements with Deloitte and Binder Dijker Otte & Co (BDO) who we engage for
project audits which do not have a specified audit firm in the donor requirements. The internal reviews are
conducted every 4 months across all areas and the review focuses on both SCI direct implementation and
where partners are used. A report of the same is normally shared with the SMT and action points followed
through by the compliance team. The audits are done by the Internal audit and compliance team who are
independent and report to the Audit, compliance and risk manager with a direct report to the CD. Apart from the
internal audits/ reviews we have project specific audits at the end of the projects, annual audits commissioned
by the Global assurance team from centre.

The organisation has exceptionally strong and comprehensive internal processes to ensure that funding is
utilized on what it was intended for and with timely and accurate audited financial reports. We have operational

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platforms, program and operational standards and key performance indicators that ensure the necessary
safeguards for the management of funds and the quality of our projects across the country program. The
Somalia Country Office has a high-functioning Finance and Administrative departments as part of the overall
structure of the office, overseen by the Country Director. The mission of our finance team, overseen by the
Finance Director, is to support the provision of a high quality, proactive and responsive financial management
and advisory service aimed at maximizing the impact of funds for our beneficiaries. One element of this is that
the country office’s finance staff will deliver an efficient and responsive service to empower program staff to
effectively undertake their management roles within a decentralized and changing environment. Equally, to
maximize the impact of funds it is vital that there are effective financial controls in place to safeguard resources
and ensure efficient use of these funds. Our finance staff act with integrity and in an ethical manner at all times.
In order to maintain good financial practices and ensure consistency in accounting and reporting, all Save the
Children programs are required to comply with the procedures presented in the Finance Management Manual
(see annex D). Save the Children uses a web-based financial management system, Agresso, which enables
financial information to be accessed in real time and with greater accuracy and detail.

Technical Working Groups (TWG): There will be separate TWGs for Monitoring, Evaluation & Research
(ME&R), Gender, Health, and Nutrition. The TWG will be composed of key technical staff drawn from Save the
Children, the donors (Swedish Embassy and SDC) and the MOH. The TWG will meet monthly or on an ad hoc
basis as required by the programme, depending on priorities, objectives and emergencies. The Project
Manager will chair the TWG meetings to help ensure better sharing of information. The TWG will be responsible
for: Providing technical advice and quality assurance; Providing technical support on the development of
guidelines, curricula, materials and tools; Ensuring that models and approaches are harmonised across the
project locations; Ensuring consistency and compliance with international best practices and standards; Regular
planning and reviews of progress; Identifying challenges and solutions; Producing timely documentation and
communications; Leading on technical revisions and adaptations to project interventions in line with project
reviews, research findings and continuous learning and feedback; and Reporting on programme outcomes.

List of Annexes

A: Log frame
B: Budget, budget notes and CAM calculator
C: Work plan
D: M&E plan
E: Project risk assessment
F: HR Plan
G: Procurement plan
H: Save the Children Capacity statement

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