Reducing the gap in mental health services in Somaliland

King’s Global Health Partnerships has worked with the government, health facilities and higher education institutions in Somaliland for over 20 years to support efforts to strengthen the health system. Improving the quality of mental health care is a core part of our five-year strategy.

KGHP spoke with Dr Liban Ahmed Hersi, the Deputy Director of the newly formed Mental Health Department to learn more about the mental health challenges facing Somaliland and what the new national plan hopes to address.

1) Please could you tell us about mental health in Somaliland. What are the main mental health challenges the country faces?

We have many mental health challenges in Somaliland. Historically, there has been no national budget allocated for mental health services. Mental health care has been largely dependent on donations from private individuals or foreign aid organisations.

Many mentally ill patients end up in private mental health institutions called Ilaajs [an Arabic word meaning ‘cure or treatment’]. These ilaajs are often run by religious or traditional healers, and are not licensed by the government. They may not follow government guidelines or protocols for treatment, and human rights are not adhered to, or they may fail to comply with the Convention on the Rights of Persons with Disabilities (CRPD). Due to lack of trained human resources in these private mental institutions, some patients are chained and beaten. In the capital city, Hargeisa, there are around 20 private mental institutions, of which the largest has more than 400 patients.

Mental health awareness in Somaliland is very low. Many communities perceive mental illness as something caused by jinn or black magic, so families take their mentally ill relatives to religious or traditional healers. Changing these public attitudes is a big challenge for us.

Until recently, there were only five public, mental health institutions in the country - in Berbera, Borama, Gabiley, Hargeisa and Burao.

In the eastern regions, Sool and Sanang, which represent a large proportion of the country’s total area, there were no public mental health facilities. And there are no primary health care-based, mental health services in the country. We also lack human resources and training in mental health. We have very few psychiatrists, psychiatric nurses and other trained mental health professionals.

2) How does the mental health strategy aim to address these challenges?

We have four priority areas in our new mental health strategy. The first is to improve the leadership and governance of mental health in Somaliland. Since we established the Mental Health Department, we have improved leadership and governance at the central level. We now have a Director, Deputy Director and four sections responsible for admin and finance, mental health information management, mental health services, and public education and advocacy. At the regional level, we have appointed Mental Health Coordinators to be strategic ambassadors for mental health and to implement mental health policies.

The second priority in our strategic plan is to improve human resources for mental health. We have trained about 450 mental health professionals in the mental health GAP professional tool (mhGAP-IG), which integrates mental health services into primary care.

Our third priority is to expand mental health services into the community and primary health care services. We have built two new mental health hospitals in the eastern regions of Sool and Sanang, where there was previously no provision.

They are big hospitals with 25 male beds and 15 female beds each, inpatient and outpatient departments, nursing stations, doctors’ rooms, pharmacy and recreational area. We have provided vehicles for regional outreach activities and medications to the regional mental health facilities.

Regional mental health teams are already doing community outreach activities, as our plan is to integrate mental health into primary health care centres across Somaliland. The teams conduct awareness raising activities, treat patients, and provide medications within the community health centres. 

These outreach activities have already started but this is the area where we need the most support, as mental health provision for the community and within primary health care requires huge resources to cover all the needs.

The fourth priority is to improve mental health information management systems. We have already established a section under the new Mental Health Department, responsible for this area of work. We have recently developed a mental health service monitoring tool with several indicators to measure mental health activities, which regional health care providers must report to the mental health department on a monthly basis.

3) What challenges do you anticipate in implementing the strategy?

In the short time that the mental health department has existed, we have achieved a lot in terms of raising mental health awareness, service expansion, human resources training, and coordinating private mental health institutions and organisations that work in mental health in Somaliland. Just this week, we delivered a two-day training in mental health and human rights for staff from private mental health facilities.

Whilst we have started delivering some activities around these four priority areas, there is still a lot more to be done and we need external support, particularly on mental health integration into the community and expansion of mental health services. It will require huge financial support to integrate this country-wide, across primary healthcare. Also delivering quality mental health services is a big challenge, since we lack professional mental health human resource.

This year the government introduced a small taxation on khat to generate income for mental health services. Khat leaves contain a psychostimulant drug similar to amphetamine.

With this small central budget generated from taxing khat, we have built the two new mental health hospitals in the eastern regions. But it’s not a stable source of financing. Khat is imported from Ethiopia and supply can be seasonal and unpredictable, or fluctuate due to trade challenges. So we need other sustainable sources of income.

4) What opportunities do you see for partners, like KGHP, to support implementation of the mental health strategy?

One of the most important things we need is collaborative research around the impacts of mental health interventions. We need to work with higher education and research institutions like King’s College London to identify and use standardised mental health measurements and indicators, in order to implement evidence-based mental health service delivery in the near future.

Also, we need to standardise mental health training for our health care professionals. We need our mental activities to be carried out in a dignified, culturally appropriate, interdisciplinary and multisectoral way, and with measurable outputs. Hence, we need research expertise and mentorship from institutions like King’s College to advise us on best possible approaches to implementing our mental health strategic plan. And to help us in adopting new models for mental health implementation in our context, so that we can scientifically assess, monitor and evaluate our efforts, to know whether we’ve fulfilled our aims or not.

We have developed our framework model and have achieved a lot so far, but we need support from KGHP in the next few years, in developing health workers' expertise and training, securing funds and writing proposal grants, so that we can achieve the priority pillars in our mental health strategic plan.