Research and Evaluation team: Raqiya, Abdiaziz Ali Ahmed, Ann Wanjiku and Ken Lee.
Sector: Labour and productivity
Location: Hargeisa, Somaliland
Sample: 14,280
Target group: Individuals (15- to 50-year-olds)
Project overview
The Non-Communicable Disease (NCD) Project in Hargeisa, Marodijeh region is a targeted initiative aimed at addressing the rising burden of diabetes (DM) and hypertension (HTN) among individuals aged 15 to 50. The project seeks to reduce premature mortality associated with these conditions by tackling key constraints on both the demand-side (e.g., lack of awareness about NCDs) and the supply-side (e.g., lack of an NCD centre, trained workers who can provide patients with guidance) of the rising NCD problem.
Background Information
Somaliland is currently in a phase of epidemiological transition where population growth, urbanisation, ageing, and improved standards of living will soon contribute to a growing burden of disease from NCDs. In a recent study, 18.2% of patients visiting hospitals in Hargeisa and Burao suffered from NCDs, with DM and HTN accounting for most cases at 13.7% and 7.5% of total visits, respectively.
Although precise data on diabetes in Somaliland is lacking, World Bank estimates indicate a DM prevalence of 6.5% in Somalia, higher than the average rates for East African countries like Ethiopia (3.3%) and Kenya (3%). The impact of NCDs in Somaliland is severe, with over 30% of all deaths attributed to NCDs, all occurring prematurely. Health Management Information System (HMIS) data suggest even higher NCD-related mortality, at 48.1% over the past five years. Given that there is no standardised death registration protocol in health facilities, and the fact that many deaths occur outside health facilities, it’s possible that these figures are an underestimate.
Complications from NCDs are also increasing. About 75% of renal failures in the country are attributed to complications from DM and HTN. Preliminary assessments at HGH reveal that 23% of patients with NCDs suffer from both conditions, and 70% of DM and HTN cases occur in individuals aged 20 to 55—the prime working years. Thus, the data suggest that the burden of NCDs is not only high, but also economically costly due to its impact on the productivity of the labour force.
Intervention details
We want to solve two broad categories of problems. First, many people do not know that they have a DM or HTN. Not only are people unaware that they may be sick, but they are also unaware of the benefits of risk reduction and healthier lifestyle habits (e.g., diet, exercise, etc.). This leads to lower-than-expected demand for NCD-related treatment services, rapid development of complications and premature death. We want to solve this awareness problem.
Second, there is a lack of specialised NCD services in Somaliland. The existing hospitals do not have specialised clinics for NCDs. Thus, they cannot provide services for managing and treating DM and HTN. As a result of this lack of supply, a growing number of patients travel to other countries to seek care. Due to the high cost, this is not an option for all people.
This intervention includes two components that tackle these issues through increasing the supply of clinical services and creating awareness.
- Community screening camps
Our approach involved community-based screening and education activities to educate the public and promote early detection. We primarily targeted working age adults for this study since our goal was to reduce the economic impact of undiagnosed NCDs on the working age population. To reach this population, we engaged with institutions such as schools, universities, workplaces, and community organisations to mobilise people to attend the screening camps. In addition, banners and information about DM and HTN were displayed at suitable places to maximise information reach.
We organised screening camps at various community locations, including secondary schools, universities, mosques, sports events, shopping centres, and workplaces. Each screening camp was staffed by a team of five healthcare professionals, including nurses, a laboratory technologist, and a registration officer. At each camp, individuals underwent screenings for blood pressure, blood sugar levels, body mass index (BMI), and other health indicators. Along with the screenings, we provided health education and advice on lifestyle modifications to help reduce the risks associated with these diseases. All patients with abnormal results were referred to specialised centres for further follow-ups.
- Pharo Foundation NCD Centre at HGH
We established a first-of-its-kind NCD-focused centre at Hargeisa Group Hospital (HGH) to deliver specialised, high-quality clinical, preventive, and follow-up services for patients with diabetes (DM) and hypertension (HTN). This centre serves as a referral hub for district health centres, hospitals, and general practitioners, ensuring a coordinated approach to managing NCDs. Additionally, individuals with abnormal results from our community screening camps were directed to the centre for further evaluation and care. Th study also integrated an electronic management system at the HGH to improve outpatient services at the facility
- Capacity building for health practitioners
To enhance the integration of NCD services at Hargeisa Group Hospital (HGH) and regional health centres, the project conducted extensive capacity-building activities, successfully training 500 health workers. Key training activities included; Training of Trainers (TOT) for Nurses, Training for General Practitioners and hospital managers/directors and supportive supervision. This effort expanded the number of health centres equipped with staff proficient in the prevention and management of diabetes (DM) and hypertension (HTN).
Methodology
In this case, it is difficult to rigorously measure causal impact (defined as the difference between a “factual” and “counterfactual”) at a reasonable cost. This is because, in addition to tracking outcomes among beneficiaries, we would need to track a comparison group. Yet this program was carried out on a community scale, making it hard to identify groups of comparable populations unaffected by our intervention. To evaluate this program, the research team systematically tracked key indicators such as the number of individuals attending screening camps, diagnosis rates, follow-up visits, and evidence of behavioural changes among participants. This approach enabled the RE team to determine whether the assumptions underpinning the program’s design were reasonable and provided critical insights into the program’s cost-effectiveness.
Data from the screenings were captured and stored in an electronic medical records (EMR) system, which streamlined follow-up appointments and allowed for better monitoring of health trends within the community. Key data collected included personal information (name, age, mobile number, and residence), along with health indicators such as weight, blood pressure, BMI, and blood sugar levels.
Results
This pilot study is currently in its implementation phase, but results from the first year demonstrate significant progress in raising community awareness and increasing engagement with the NCD Centre. Key achievements include:
- Increased Public Awareness: Over 10,000 individuals have been screened through the project, with 65+ community campaigns conducted, primarily targeting the working-age population, which constituted 77.8% of those screened. Among the screened individuals, 13.6% were diagnosed with hypertension, 5.0% with diabetes, and 4.5% with both conditions.
- NCD Centre Utilisation: The NCD Centre has seen a marked rise in daily visits, reflecting increased community interest in diagnosis and treatment. Between April 15, 2024, and September 30, 2024, the Centre recorded 6,624 visits from 2,963 unique patients.
- Capacity Building: The project has focused on strengthening the skills of healthcare professionals, training 281 health workers to date, representing 56% of the target. These professionals have gained critical expertise in the prevention and management of diabetes and hypertension, enhancing the healthcare system's ability to address non-communicable diseases effectively.