The number of confirmed COVID-19 cases continues to rise in Somalia including associated deaths attributed to coronavirus disease. While the cases grow in numbers, the health systems in Somalia is being rapidly confronted with increasing demand for patient care from COVID-19. When health systems are strained and overwhelmed specially in fragile and vulnerable settings like in Somalia where adequate mechanical ventilators and other critical care support for patient care are basic, rudimentary or absent, mortality from the outbreak may increase substantially over time. Since the beginning of the outbreak, seven associated deaths out of 135 cases have been reported by the government in Somalia as of 19 April 2020.

It is also one of these situations where essential including life-saving health services are disrupted and all healthcare resources including essential supplies and health manpower are re-prioritized and re-directed towards reducing deaths from a crisis of the magnitude of COVID-19 since the situation will receive increased media attention and there will be growing demand and political pressure to reduce direct mortality from the outbreak.

However, it is also in this type of situation where the criticality of maintaining other life-saving health services during this period of outbreak of such nature and scale might be overlooked and the headline of figures of deaths will mask the need for essential health care specially for mother, children and other vulnerable groups. During the 2014-2015 Ebola outbreak, analyses suggest that the increased number of deaths caused by measles, malaria, HIV/AIDS, and tuberculosis attributable to health system failures exceeded deaths that were directly attributable to Ebola virus disease (EVD).

During this currently ongoing outbreak of COVID-19 in Somalia, it is plausible that if the virus transmission cannot be slowed down rapidly, the patient surge and its increasing demand for care will be overwhelming, put an enormous pressure on the fragile health system and if the situation reaches to a breaking point, the catastrophic impact will also felt in other areas of life-saving services such as immunization, maternal care and other services aimed at limiting deaths from preventable diseases.

Over the years, the country has made several gains in the health sector. The country has remained free from wild-polio virus since 2014. Without maintaining time-sensitive and active surveillance system for AFP throughout the country including environmental surveillance even during this period of COVID-19 response, we might see a resurgence of polio virus. In 2019, WHO’s staff for polio eradication programmed helped reach out over 3 million under 5 children with lifesaving polio vaccine, collected 75 sewage samples and also detected 361 AFP cases to keep the fight on eradicating polio virus completely from the country. If these polio activities are not maintained or sustained even during this period of COVID-19, this will push back all the gains made over the years in the country to end polio.

Maintaining essential health services during this ongoing COVID-19 outbreak will also be critical to save lives from other ongoing infectious diseases threats in the country such as measles and cholera. The cholera outbreak continues to kill innocent lives and so far in 2020, cholera has claimed 11 lives and making another 2600 people sick. Any disruption of essential care and other key health interventions for managing cholera and other infectious disease threats may lead to an upsurge of cases and excess deaths. Maintaining these critical and life-saving services is the only way to end cholera by 2030 and limit avoidable deaths from this disease by 90%

While commenting on the need to ramp up essential health services and key interventions aimed at protecting health gains achieved over the year, Dr Mamunur Rahman Malik, the WHO Country Representative for Somalia said “While there is a need to fight with this virus on all fronts, we also need to ensure that essential health services having direct impact on health and saving lives are also maintained even during a crisis of this scale. Our gains in protecting children against vaccine-preventable diseases, our victory in eradicating polio virus from the country, our focus on leaving no one behind for achieving universal health care coverage will be lost forever if we can not support the health systems to meet the increased demand for health care for COVID-19 and yet maintain the health services that are life saving in nature. Countries will need to make difficult decisions to balance the overwhelming demands of responding directly to COVID-19, while simultaneously engaging in coordinated action to maintain essential health service delivery specially to prevent health systems from collapse”.

Working in partnership with other UN agencies such as the United Nations Children’s fund (UNICEF), United Nations Population Fund (UNFPA), International Organization for Migration (IOM), the United Nations High Commissioner for Refugees (UNHCR) and the United Nations World Food Programme (WFP), the country office is supporting the health authorities to constantly improve and maintain the essential health services for mother, women, children, people with disability and the elderly people specially in IDP and refugee camps while balancing, as well, the extra demand for COVID-19. The primary health care centers which are the bedrocks of essential health care in Somalia have been supported with personal protective equipment for the healthcare workers managing these centers as an incentive to keep the center open while making sure that the healthcare workers have the training and knowledge to do triaging for COVID-19 for high-risk patients, refer them to higher facilities and yet maintain their routine health care services.

While the EWARN- the early warning disease surveillance system, currently covering 535 out of 1075 health facilities in the country with an estimated 6.5 million population coverage, has been expanded to cover not only 14 epidemic-prone diseases, but to include the case definition of COVID-19 as another reportable health condition. The system enhancement has allowed WHO to monitor the trend of severe acute respiratory infection as a proxy for COVID-19, but the addition of distinct case definition of COVID-19 in the EWARN has been useful to capture any suspected case early.

Maintaining the routine immunization services for childhood diseases remain another key challenge specially during this situation of physical distancing. However, efforts are underway to support health facilities deliver immunization services yet maintain social/physical distancing. A country where one in every 10 children doesn’t receive life-saving vaccines, the suspension or breakdown of routine immunization services will have a devastating toll on the lives of vulnerable children in the country. Last year, WHO supported the health authorities to reach out to every child with life-saving vaccines resulting in reaching out to 462 050 children under 1 year out of 602 195 (77%) completing the three doses of the pentavalent vaccine while 430 275 (71%) received the measles-1 vaccine. Any disruption of routine immunization services will be a severe set back in WHO country office’s strategy to make every child count is its health programme.

A well-organized and prepared health system has the capacity to maintain equitable access to essential service delivery throughout an emergency, limiting direct mortality and avoiding increased indirect mortality. With the current situation of COVID-19 where caseloads are increasing and the pressure is mounting on the health systems, the capacity to maintain routine service delivery in addition to managing increased demand for COVID-19 patient care need to be maintained at any cost to protect the health gains achieved over the year. The WHO country office is supporting that to happen through strategic shifts ensuring that increasingly limited resources provide maximum benefit for the population.

Our operations response to COVID-19 is supported by ECHO, DFID, UN CERF, Embassy of Switzerland and Italian Development Cooperation