This study has revealed strengths and gaps in the capacity of selected hospitals to manage NCDs. Significant variations in the capacity of hospitals were observed. Location, level of healthcare services, and the source of funding of hospitals have significant impact on their capacities for effective NCDs management. The observation of few doctors and the lack of doctors with specialist trainings are consistent with previous reports indicating the shortage of doctors globally [15–17]. The WHO [18] estimated that only 9% of 3.6 million health workers across 47 countries in Africa in 2018 are doctors. Factors such the migration of doctors from LMICs to high-income countries (HIC) [19] and poor infrastructural development have been implicated. The UK National Health Service [20] reported that the proportion of Africans in the UK healthcare workforce has increased from 1.8% in 2016 to 3.1% in 2022.
The Somaliland’s National Health Workers Survey conducted in 2015 revealed that the country has only 197 doctors, 1,256 nurses and 344 midwives who provide healthcare services for a population of 3.5 million people. This could be due to the civil war (which ended in 1991) which drove many health workers out of the country and destroyed the country’s ability to train new health workers [21]. The poor economic situation in Somaliland is also discouraging the returning of foreign trained doctors to Somaliland [22]. Though it is possible that doctors with specialist trainings may be available at Hargeisa General Hospital, we are unable to report data from this hospital in this study. Even if this is the case, the number of such doctors will be insufficient for the entire country.
Health workers in Somaliland were more concentrated in urban areas. Specifically, 85.2% of available doctors in the hospitals surveyed were in UHs though the population of nurses and midwifes is more evenly distributed. This indicates that nurses and midwifes provide the majority of healthcare services across rural areas in Somaliland where NCD cases are higher [9]. Moreover, the lack of adequate skills required for effective management of NCDs has been previously reported among nurses in rural Somaliland communities [23]. This assessment also revealed that there are more health workers at RCs compared with GHs in Somaliland. A similar trend was observed for PrHs and PHs. This is consistent with the structure of the health system in Somaliland [24]. According to the Somaliland’s Essential Package on Health Services (EPHS), RCs are designed to be served by generalist doctors while regional hospitals (or GHs) provide more specialist functions. The dearth of doctors with specialist trainings in Somaliland could account for fewer workers at GHs. In addition, it is possible that the management of all cases of NCDs, irrespective of the level of severity, is taking place at the RC level. The shortage of other health workers such as Community Health Workers, NCD counsellors, Foot Care Specialists, Social Workers, Nutritionists and Diabetes Educators suggests that some essential services were ineffectively delivered in the country.
Assessed health facilities surveyed have adequate number of basic equipment and facilities for the management of NCDs. However, none met the WHO-PEN standard for tools required for effective management of NCDs. Despite the fact that the Somaliland Health Ministry recently launched a database for health information, paper files were still used across all hospitals in Somaliland for record keeping. This represents a challenge which will significantly affect the accuracy and overall utility of the new information platform. NCD registers were generally lacking across hospitals in Somaliland, and this means that accurate records of NCDs prevalence and management may not be kept. This will also prevent effective monitoring of clinical outcomes in people living with NCDs and make effective planning/policymaking difficult [25].
The availability of basic equipment in UHs, GHs and PrHs was better than RHs, RCs and PHs respectively. However, the lack of basic equipment in some hospitals is worrisome. It indicates that healthcare workers in these hospitals will be unable to deliver quality care services. The lack, non-functional nature, and lack of expertise for effective utilisation of advanced equipment across selected hospitals will also contribute to this problem. These observations are consistent with what has been previously reported in a similar study conducted in Uganda [14] and this indicates that the lack of advanced equipment may be a common phenomenon in LMICs. Echography and Computerised Tomography (CT) scan are imaging techniques which are essential for the monitoring of complications arising from many NCDs [26]. However, none of the hospitals surveyed in this study had these facilities.
All hospitals surveyed have the capacity to conduct general. This is consistent with the fact that basic laboratory facilities and laboratory technologists with basic expertise are available in these hospitals. However, the capacity to conduct advanced diagnostic tests across the hospitals differ significantly. Glycated haemoglobin (HbA1c) test is routinely used for monitoring diabetes progress [27] and that this test cannot be conducted in some RHs, RCs and PHs means poor services for people living with diabetes. The lack of capacity for oral glucose tolerance test, which is the gold standard procedure for diabetes diagnosis [28], and foot care will further worsen the burden of diabetes among patients. These observations are consistent with challenges that have been previously highlighted as facing efforts to tackle non-communicable diseases at the rural level in many countries [29]. The lack of capacity for breast and cervical cancer screening and diagnosis may account for the absence of cancer prevalence data in the recently published Somaliland Health and Demographic survey [9]. Long-term supports and community engagement are important for effective management of NCDs [30]. The fact that these are lacking in many hospitals suggests the need for interventions to build capacity in this regard.
The WHO PEN recommended access to NCD medications and treatment guidelines summarised in Table 1. Though access to first line medications is not a challenge, it is not certain if the people in Somaliland could afford these medications. Also, the shortage of second line medications means that the management of NCDs complications and drug-resistant cases may be difficult. Also, the observation that available guidelines were part of a general national guideline for all types of diseases, limited in the coverage of NCDs and lack content on important risk factors (such as screening and management of tobacco smoking, alcohol consumption and mental health) signifies the need for urgent review.
The importance of referral systems in ensuring that patients have continuous care and are able to access services in other health facilities has been reported [31, 32]. This is particularly important in Somaliland where a marked difference in the availability of health workers and facilities between rural and urban hospitals. High costs of imaging revealed by this study is consistent with the lack or non-functional nature of advanced equipment that could have been used for imaging in-house. These, in addition to lack of cutting-edge expertise in technologists, could also be true for the high costs of laboratory services), and represent areas that urgent interventions should address.