- 1 Systematic mapping studies addressing mental health-related domains/issues in Somalia
- 2 Health system determinants of mental health
- 3 Disaster and trauma-related determinants
- 4 Social and cultural determinants
- 5 Discussions and recommendations for priority setting in mental health in conflict settings
- 6 Limitations of the study methodology
- 7 Conclusion
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The systematic mapping conducted revealed a wide array of topics across several major research/study areas in the existing literature addressing mental health issues of Somalia.
All databases searched provided 25,700 records. After exclusion, the number of identified records was reduced to 9340 and 1401 of these could be categorised into one of the domains of interest addressing mental issues in Somalia. The distribution of publications by mental health fields/sub-fields is diagrammatically represented in Fig. 1. The percentages are based on a total of 1401 records.
Growth trend of the distribution of peer review publications pertaining to different mental health-related fields and sub-fields, presented as percentage of total peer reviewed publications addressing mental health in Somalia from 1991 to May 2020
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Among the major searched domains, policy-related determinants and mental health services dominated (1042 records, 74.4%), followed by the disaster-related determinant and women’s health consequences (550 records, 39.3%). A total of 419 (29.9%) records dealt with longitudinal studies, while 361 (28.5%) and 321 (22.9%) records addressed training for mental health professionals and traditional practices, respectively. Among the policy-related domains, services, human resources, financing, policy and legislation, and mental health priorities, were represented with 74.4%, 48.8%, 21.6%, 13.8% and 8.4% records, respectively.
The disaster-related determinants were by far the largest set, comprising eight areas: women’s health consequences (39.3%), war trauma (32.2%), physical and mental symptoms (22%), adolescent refugees (17.8%), forced migrants (13%), unaccompanied refugee minors (5.4%) and collective trauma (0.6%). The disaster-related determinants were followed by social determinants: traditional practices (22.9%), stigma (21.9%), perceptions (13.3%) and traditional healers (4.7%). The behavioural determinants were as follows: self-harm (18.8%), substance abuse (16.1%) and suicide (9.1%).
Health system determinants of mental health
Mental health services
Although the number of psychiatric beds has increased slightly in recent past based on the data from 1991 to 2016, the ratio of number of beds for mental health in general hospitals falls abysmally behind the Eastern Mediterranean region (EMR) and the global average (Fig. 2). Therefore, Somalia remains severely underserved in terms of mental health services. Furthermore, community mental health, whether as part of integrated primary health care (PHC) services or stand-alone services, is virtually non-existent across the country .
Source: WHO’s Global Health Observatory )
Number of mental hospitals and mental health outpatient facilities per 100,000 population in Somalia in 2016 (
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Since 2009, the self-declared independent Somaliland expanded its mental health services across five main cities: Hargeisa, Berbera, Borama, Gabiley and Burao. In total the bed capacity increased to 250 for a population of 4 million [4, 27]. Whereas across the rest of the country, psychiatric units within general hospitals have been established in Puntland (Bosaso) and South Central (Mogadishu, Baidoa and Beledweyne) but the bed ratio remains one of the lowest globally. The rural and remote communities find it more difficult to access and maintain contact with the existing mental health services.
Although a reliable source of data on human resources for health is lacking in Somalia, owing to dismal conditions of overall human resources for health, there is apparently a severe paucity of mental health workforce in the country . Research shows that the quality of mental health care in low‐ and middle‐income countries (LMIC) faces at least four key challenges: limited resources, weak health system, lack of standardised services, and diverse cultural environments . In this light, limited resources in Somalia are evident with the very low median number of mental health workers.
One study provides evidence that there were only three psychiatrists working in public facilities in Somalia in 2010 . In most regions, only general practitioners acting as psychiatrists are available. In recent years, nurses and social workers have been trained by international NGOs and/or WHO in two short courses of training on mental health conducted initially in Bosaso and later in Hargeisa. Further, the country is currently experiencing a proliferation of for-profit academic institutions offering various academic programmes including health-related ones. However, there is a lack of frameworks and regulation for ensuring quality education at both federal and member state levels. Moreover, want of an accreditation system raises some serious doubts on the basic training and standards for medical professionals engaged in provision of mental health services in Somalia. There is an overall lack of data regarding professional training and continuing professional development [3, 4, 9].
Mental health policy and legislation
Somalia’s first ever mental health policy and strategy was formulated in 1986 by the Ministry of Health with the help of WHO. However, due to the beginning of unrest in the late 1980s which eventually led to the collapse of the national government in 1991, the mental health initiatives were never realised .
Currently, there is no mental health legislation in place in Somalia to protect the lives, rights and integrity of people with mental illness [4, 9]. Somaliland published a mental health policy in 2012 to set out plans to develop and organise mental health services, including the development of community-based services, training, research and legislation. However, due lack of funding and political will, the policy remains only on paper and is yet to be implemented . Recently the Federal Government of Somalia has moved to redevelop key policies and strategies including mental health and has established a mental health portfolio.
A legal and policy framework is crucial in the mental health sector considering the widespread level of stigma, discrimination and human rights abuse (Human Rights Watch, 2015). The Human Rights Watch 2015 report depicted significant and ongoing human rights violations of persons with severe mental illness in Somaliland . The abuses included, among others, physical violence and chaining or locking up of individuals with mental illness in psychiatric facilities, jails and spiritual healers’ centres or even in families’ backyards. It is estimated that 170,000 people with mental health problems in Somalia are kept in chains. Neglect, inadequate nutrition and poor hygiene is rampant [13, 29].
As the country slowly rises from the ashes of years of anarchy, it is prudent to establish comprehensive and progressive legislation and policies for mental health and other vulnerable sectors in order to serve and protect their rights as equal citizens.
Mental health financing
Evidence shows that material, financial and human resources for mental health in most low- and middle-income countries is dismal. In fact, more than 70% of African and 50% of Southeast Asian countries spend less than 1% of their health budget on mental health . In the case of Somalia, the long-standing instability has severely curtailed the government’s ability to provide and fund essential services.
To overcome Somalia’s chronic emergency, the international community has allocated funds to different sectors including health. Except for a comprehensive review published by the World Bank (WB) in 2008 , the information of health sector aid financing in Somalia is dismally negligible. In the last decade, horizontal health system strengthening programmes lagged behind vertical programmes. However, since 2010, a more determined health systems strengthening approach has been adopted with integration funding across Somaliland, Puntland and South Central [31,32,33].
Despite the significant need for mental health services, resource allocation is largely donor-related but even then, very few NGOs and international organisations focus on mental health in Somalia. As such, any meaningful improvement of the mental health system in Somalia is likely to be in jeopardy without significant investment in this sector.
At national and regional levels, no government agencies exist that are mandated to source, inventory, purchase and distribute essential medicines. At the service provision level, essential psychotropic drugs that are crucial for medical treatment and for managing the most acute cases initially are not always available at the end-user level.
Limited epidemiological studies have been conducted determining the prevalence of mental illness among Somalis and Somali refugees. Available research has suggested that refugees are at risk for the development of a variety of psychological disturbances including depression, anxiety and post-traumatic stress disorder (PTSD) [3, 27, 34]. However, inconsistency is found in the results reported about prevalence and severity of mental illness among Somali refugees. The conflicting results in the existing literature may be attributed to the complexity of cross-cultural survey techniques and methodological inconsistency as well as interpersonal variability among patients regarding psychological resiliency and psychopathological symptoms . There are limited studies within the country although two earlier studies show high rates of mental illness in the country with one in three and one in every two households in Somaliland  suffering from some form of mental illness.
Recently, the Joint Multi cluster Needs Assessment survey highlighted a substantial prevalence of mental health issues among the affected population in Somalia [10, 34]. Some case studies of individuals from Somalia show high rates of schizophrenia, bipolar disorder, PTSD, depression, mania and psychosis. There are also individual reports of repressed traumatic memories manifested through bouts of depression, anxiety, PTSD, and thoughts of suicide and self-harm.
Suicide and self-harm
Available data on age-standardised suicide rates per 100,000 population in Somalia from 2000 onwards are summarised in Fig. 3 and compared with the global and EMR averages for the same years. Although mental health disorders have been reported as one of the highest and affect one third of the Somali population, [3, 15, 36] the suicide rate in the country has been less than the global average. However, the rate in Somalia has been higher than the average suicide rate for the EMR. Figure 3 depicts the number of suicides in Somalia annually from 2000 onwards. It is also evident that the suicide rate has increased in males and females in Somalia from 2000 onwards while the average rate declined globally and in the EMR during this period (Fig. 3).
Source: WHO’s Global Health Observatory .)
Age-standardised suicide rates per 100,000 population in Somalia from 2000 onwards as compared with as compared with global and EMR averages in the same years (
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However, unlike suicide rates, the disease burden of self-harm in Somalia has a declining trend in both sexes since 2000 [37, 38]. Like suicide, self-harm has always been higher in males in Somalia . Contrary to suicides, the disease burden of self-harm has been far lower in Somalia than that in most of the EMR states.
There is scant information available on the prevalence of substance abuse in Somalia . Figure 4 presents the disease burden of substance use disorders in Somalia, mainly khat but also opioid, cocaine, amphetamine, and cannabis. The trend shows that from 1991 (onset of the civil conflicts) substance use increased in both sexes until 2000 and then almost plateaued. However, in recent years a tendency of increased drug use can be seen. Nevertheless, the disease burden of substance use disorders has the lowest values in Somalia among the EMR countries. To date, the most commonly used substance is khat, a psychoactive substance indigenous to East Africa and the Arabian Peninsula [39,40,41]. Although in the past chewing khat was a traditional social norm commonly consumed primarily by adult men, the consumption and patterns of use has shifted and now increased addiction is being seen in women and youth [39,40,41].
Source: Global Burden of Disease )
Disease burden of substance use disorders (disability-adjusted life years per 100,000) in Somalia (
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Physical/mental symptoms and collective trauma
A study on Somali refugees showed that those exposed to collective or personal trauma experienced more psychological distress . Several studies show significant mental health issues associated with conflict and refugee settings [3, 24, 42, 43]. The same is true for Somalis within the country and as refugees [3, 24, 43, 44]. These psychological experiences have been diagnostically classified under the categories of PTSD, anxiety and depression. Somalis also acknowledge feelings of hopelessness, despair, anxiety and anguish as part of their symptomatology, despite not explicitly labelling such experiences and symptoms as PTSD or depression [42, 43]. The consequences of trauma among Somalis have also been described in somatic terms with emphasis on headaches and other unexplained body pains that seem untreatable with physical health remedies offered by health services [24, 43, 44].
Social and cultural determinants
Somalis’ perceptions of psychological wellbeing are dichotomised like health and illness, that is, there are only two categories: mentally well and mentally ill people. Mild forms of mental disorders are usually neglected and not considered as serious problems requiring any psychological assistance [24, 35]. Since cultural and faith healing are deeply rooted and widely practiced by Somalis [43, 44], understanding of the causes of mental illness or psychosocial distress are often seen as spirit possession (jinn), witchcraft (sihr), or evil eye (eel). Treatments include exorcism (ruqya) and the recitation of verses of the Qur’an by the individual, family members, or imams and other religious or traditional healers [43, 44]. The belief in cultural and spiritual causality of psychosocial illness has a profound effect on the understanding of illness and help-seeking for people with such beliefs. In fact, across the country, cultural and spiritual aspects remain the most important attribute of psychosocial illness and, as such, first line treatments typically involve some form of religious and traditional healing .
Significant stigma and discrimination in Somali society conceals mental health issues [3, 24]. Stigma has damaging effects like distancing from a family diagnosed with mental illness and reluctance to seek clinical help or professional assistance. Stigma is, therefore, one of the main barriers to engaging with mental health services in Somali society [3, 24]. Health service seeking is also hindered by cultural gender norms in the society. Normally, women refrain from discussing rape and sexual assault with care providers, or to seek mental health treatment from medical professionals. Men, on the other hand, often choose self-medication in the form of substance use, mostly khat [3, 4].
Due to the collapse of the nation state and community reliance on spiritual healing, there has been an explosion of spiritual healing programmes popular known as ilaaj (healing in Arabic). Although these centres are widespread and highly utilised, currently limited information is known about them in terms of the numbers, evidence supporting their treatment and the number of clients in their care. While crucial as community resources, there is documented evidence of human rights transgressions in the form of chaining and exorcism-related physical abuse [13, 46].
Discussions and recommendations for priority setting in mental health in conflict settings
As the country staggers toward political, social and economic recovery from the nearly four decades of conflict and lack of strong central government, it is crucial to lay a solid foundation of sound mental health policies, strategies and infrastructures to address the myriad needs of its citizens. In this paper, we propose the following four key strategies to address the monumental mental health needs of the country. These are: establishing and strengthening governance for mental health and effective leadership, implementing human resource policies, regulation and training, provision of comprehensive integrated community-based mental health services through PHC and mental health financing.
Establish and strengthen governance for mental health and effective leadership
Strong and effective mental health governance overseen at a senior ministerial level is needed to coordinate activities of the department of mental health at federal and state levels. Such a high-level portfolio is crucial to address the development and maintenance of an integrated mental health system as part of the general health care system. Mental health leadership is required to develop, regularly review and update policies, strategies and legislation [47, 48]. There is a need for a mental health department/directorate responsible for development, coordination, monitoring and evaluation that is adequately staffed and resourced. Chief among health infrastructure needs is to create an inclusive mental health policy and strategy that is backed by a progressive mental health legislation . Considering the systemic neglect and abuses of those with mental illness at community and health facilities, it is prudent to have a mental health law that is clearly aligned with the United Nation’s Convention of Rights of Persons with Disabilities (CRPD) human rights framework . The Federal Republic of Somalia has already ratified and is signatory to the CRPD and as such, any mental health law must follow the letter and spirit of the CRPD to ensure the rights of persons with mental illness and other psychosocial disabilities are fully protected under the law of the land and specifically laws pertaining to their treatment in the community and service systems.
Implement human resource policies, regulation and training
Secondly, the country needs robust health education, certification and training policies, and strategies with legal backing. Currently Somalia faces a chronic shortage of health workers which is a significant barrier in achieving UHC. In addition, due to years of an unregulated market, the country faces the risk of an unregulated and unlicensed body of health professions whose qualifications and competencies cannot be ascertained. It is within this context that a national regulatory authority is urgently required to take stock of health service providers, health learning institutions and health practitioners. Then the country needs to develop ways to assess the quality of services, education and qualifications.
One of the key innovations required is to develop an appropriately skilled workforce who can work in community setting adopting a multidisciplinary teamwork ethos, integrated into PHC, linked with expertise for referral and inpatient care, networked with local resources in a collaborative way to deliver efficient and cost- effective mental health care. This requires a transformation of roles and responsibilities of general health workers and specialist mental health service providers, such as through various types of task-sharing, and developing new cadre for mental health professionals like community mental health workers and case managers. There is a need to build the capacity of non-specialist health workforce and specialist mental health workforce to provide community-based integrated care for priority mental disorders .
Provide comprehensive and integrated mental health in community-based settings through a PHC approach
The UN adopted a resolution to support UHC in 2012 and urged countries around the world to provide quality comprehensive health services through PHC. In line with UHC and PHC, WHO developed the Mental Health Action Gap (mhGAP) guide to scale up treatments in resource limited regions. The mhGAP model is likely the most appropriate model for the Somali context as the model emphasises a non-specialty approach to service provisions where mental health support and treatment can be provided by non-specialist health workers (nurses, midwives, GPs) and community health workers at PHC and community entry points .
The mhGAP guide is a guideline to address the growing burden of mental, neurological and substance use disorders, extremely low number of mental health professionals, and shortage of mental health facilities in many LMIC . The guide identifies priority conditions based on a high disease burden (in terms of mortality, morbidity and disability), large economic costs, and human rights violations. The priority conditions include depression, psychoses, trauma-related conditions (including PTSD), epilepsy, child and adolescent mental and behavioural disorders, dementia, disorders due to substance use, and suicide/self-harm. The aim of mhGAP is capacity building of LMIC in managing mental, neurological and substance use disorders by training non-specialists to detect and manage these illnesses. The guide also facilitates delivery of the mhGAP evidence-based guidelines in non-specialised health care settings. The mhGAP has been successfully put into context in several LMIC settings [53,54,55]. The mhGAP has been introduced in two universities of Somaliland: The University of Hargeisa and Amoud University, with the intention of further cascading across the semi-autonomous region .
Mental health financing
To achieve UHC, a key target of the Sustainable Development Goals , countries need sufficient quality of health services, financial coverage or risk protection, ensuring that the services do not expose the user to financial hardship [58, 59]. Discerning with this lens, mental health issues are neglected globally . In resource poor countries, people with mental disorders have negligible access to quality health care and are consequently vulnerable to suffering and ill health . Mental health patients in such situations suffer from human rights abuses, poverty, stigma, discrimination and even premature death [28, 61, 62]. WHO Special Initiative for Mental Health (2019–2023) specifically focuses on universal coverage for mental health. WHO stresses that there is no health or sustainable development without scaling up and integrating mental health services to PHC. Somalia has the opportunity to closely collaborate with WHO and international partners to ensure mental health is a priority condition and its financing prioritised through substantial national budgetary allocation as well as external developmental support.
Limitations of the study methodology
The search terms used for the systematic mapping were applied to capture a wide range of mental health studies addressing Somalia. However, some specialised embedded niches of research, e.g., childhood mental health and mental health effected social development might be underrepresented. Moreover, lack of publications originating from Somalia and traditions regarding the dissemination of findings in foreign journals may misrepresent most of the indigenous mental health issues in the searched results. In addition, whilst a number of recommendations are made, further research is warranted to assess the effectiveness of the proposed interventions in Somalia.
This paper outlines the key issues of mental health in Somalia that require researchers, clinicians, administrators, programme planners and policy makers to comprehend the magnitude of the factors that moderate them. The vast scale of the mental health problems in Somalia elucidated in this paper warrant a dire need that the Somali government and its national/international partners should prioritise and emphasise investments in the prevention and the treatment of mental illness across the country. Based on available data/information and evidence-derived in this paper, guidelines are provided to policy makers in setting priorities for the designing of the mental health system and delivery of interventions to promote mental health and psychosocial wellbeing in Somalia.