By October 2020, the total number of confirmed COVID-19 cases surpassed 40 million worldwide, with over one million fatalities, primarily affecting the United States, India and Brazil, while many countries relatively unaffected during the ‘first wave’ experienced dramatic increases in cases (WP, 20 Oct; WHO, 21 Oct). Early on, global health experts warned of the potential for devastating COVID-19 outbreaks in low- and middle-income settings (LMIS) due to a lack of availability, inadequate capacity and poor access of healthcare systems, however confirmed caseloads across the African continent have remained relatively low, including in Somalia.
For decades, Somalia’s status as a fragile and conflict-affected state has corresponded with weak health systems and poor health outcomes for the majority of its population. Somalia, with an estimated population of 15.9 million, consists of five federal states and its capital Mogadishu in Benadir province under federal authority, with varied levels of economic development depending on the states’ level of political stability and security . Two of the country’s main economic sectors of livestock trade and remittances were negatively affected by the pandemic, including as a result of movement restrictions to control the spread of the virus . The country is among the poorest countries in the Horn of Africa and designated as a ‘least developed country’ by the United Nations (UN), with its economic development affected by protracted crises causing widespread destruction and displacement, all further complicated by the pandemic . With almost 70 % of the population living in poverty, by mid-2020 almost a third of the population was in need of humanitarian assistance due to crisis including floods, droughts, locusts invasions and COVID-19 . The pandemic was projected to reduce the expected economic growth from 3.2 % to a negative 2.5 % in 2020, while inflation increased due to nationwide price increases .
The country lacks comprehensive health services, healthcare professionals and infrastructure, alongside unequal distribution of facilities and resources, means that many people lack access to healthcare altogether . This is reflected in the World Health Organization (WHO) key health indicators for Somalia, which are among the lowest in the world, including high neonatal and maternal mortality rates, and a low life expectancy of 56.5 years . In response to COVID-19, the Federal Government of Somalia pledged US$5 million towards a healthcare response fund, to develop and rehabilitate nationwide healthcare facilities . However, the lack of current facilities means that COVID-19 testing is limited to suspected cases, thereby likely underestimating the burden of disease, with most testing taking place in the main urban centers .
The low case numbers in LMIS have to a large extent been attributed to limited testing capacities, exacerbated in fragile and conflict-affected countries such as Somalia . Some researchers argue however, that the rapid government responses, fewer (international) travel movements, limited urbanization and a relatively young demographic in LMIS has limited infection rates, as morbidity and mortality rates are associated with older age [8, 9]. Modelling studies assessing the potential impact of COVID-19 in LMIS acknowledge significant uncertainties, due to a lack of primary data on transmission and health outcomes [8, 10].
Due to a lack of access, including through COVID-19 related movement restrictions and the ongoing complex humanitarian emergency, there has been little evidence on the actual status of the pandemic in Somalia. The proportion of confirmed positive tests remained fairly stable throughout March – October, 2020. Meanwhile, WHO data shows a varied picture across the country, which makes it difficult to draw conclusions .
Somali authorities implemented rapid and drastic measures to curb the spread of the pandemic in a challenging environment. As soon as Somalia identified its first COVID-19 cases in mid-March, the Federal Government established a national response committee and an incident management system. At the onset of the pandemic, Somalia had no laboratory capacity to diagnose the disease, and screening started with temperature checks at airports and isolation of suspected cases . The Ministry of Health established a multisectoral emergency task force, deployed health workers at airports, and established isolation facilities for those arriving from high-risk countries . Subsequently border crossings were closed and in-country movements restricted, while isolation center- and critical care capacity was increased . The Ministry further developed a National Preparedness and Response Plan and Risk communication and community engagement (RCCE) strategies and taskforce, supported by national and international relief organizations [12, 14]. RCCE strategies through formal and informal channels initiated to prevent and control disease spread included the provision of a toll-free number for general advice, the use of radio, television and social media for mass health communications, with a focus on social distancing and hygiene . Community Health Workers (CHW) conducted outreach, visiting communities to identify cases based on syndromic surveillance, tracing contacts and raising awareness .
By late September 2020, Somalia had confirmed 3588 COVID-19 cases, with 99 fatalities, while the utilization rate of isolation facilities remained low at 17 % . The impact of the disease is difficult to investigate and assess however, not only due to a limited testing capacity, but also a lack of access to hard-to-reach populations in the ongoing complex humanitarian emergency, in particular during COVID-19, resulting in gaps in epidemiological trend data . As a result of the protracted emergency, malnutrition rates are high and health outcomes poor, exacerbated by the lack of health services, which puts people at increased risk of infectious diseases, including COVID-19 . Meanwhile, experts warned about the economic impact of curfews and lockdowns, control measures developed based on middle- and high-income contexts, potentially unsuitable to the local population .
The contribution of the pandemic to the existing barriers to access to populations in need poses an ongoing challenge for ensuring an effective response grounded in community experiences and priorities. Through this study, we deploy a novel remote qualitative research approach suited to fragile and conflict affected settings to gain a rapid grounded overview of how the disease and formal intervention measures impacted internally displaced and host populations, and how policy measures, local context and community responses influenced disease transmission, social and economic vulnerabilities.
Currently, there are an estimated 2.6 million Internally Displaced Persons (IDPs) in Somalia (IOM, 2020), primarily displaced due to the impact of floods or drought (72 %) and conflict (25 %) . The most recent displacement was caused by severe flooding affected the southern regions, with over 650,000 newly displaced since June 2020. One of our participants was recently displaced due to droughts and locusts destroying crops and agricultural land. Internally displaced persons (IDPs) often depend on daily wages and have limited or no access to health facilities. Acute watery diarrhea, including suspected cholera, and measles are regularly reported in clinics serving IDPs .
IDPs in informal camps were considered most at risk of COVID-19, due to continuous in- and out movements and low-quality shelters . Displaced populations often live in marginalized areas, in substandard and crowded living conditions in camps or slum settings, lacking sanitation and access to public health and social services, which puts them at higher risk of infectious diseases, including syndemic health risks such as malnutrition and underlying conditions, which often remain untreated [24, 25].
One of the main challenges of responders remains restricted humanitarian access due to ongoing insecurity, in particular in south and central Somalia. Refugees and internally displaced people (IDPs) further increase the pressure on limited health system capacity, with people often relying on private services when resources are available, or those provided by non-profit organizations . People relying on services provided by relief agencies, such as health supplies, food and cash distributions, are likely to be greatly impacted by movement restrictions. Humanitarian responders therefore rapidly drafted plans to control COVID-19, focusing on strengthening of health systems, provision of protective equipment and RCCE. International and national nonprofit organizations provided training on COVID-19 surveillance, case management and RCCE, increased investigation and testing capacity, established health and (underutilized) isolation facilities. Community Health Workers (CHW) conducted outreach, visiting communities to identify cases, tracing contacts and raising awareness (WHO, August 2020). Nonetheless a first case was confirmed in an IDP camp on 28 April . Our study takes a closer look at the experiences of these hard-to-reach populations during the early months of the pandemic.
Social determinants of health
Disease infection and transmission does not only depend on the presence of pathogens, but on complex interactions of biomedical, environmental, socio-economic and political factors . Socio-economic and health inequalities related to political and economic processes increase disease risks of resource-poor communities, especially those in countries with limited resources facing complex emergencies and limited healthcare . Globally, COVID-19 has made these health inequalities even more visible. Pre-existing poor health conditions, which put people more at risk of the disease, may be caused or exacerbated by crowded, poor living conditions and a lack of sanitation, which characterize IDP camps . These factors play a role in the risk of severe COVID-19, the ability to adhere to preventive measures, and the impact of public health approaches to lives and livelihoods. We therefore analyze our findings using a conceptual framework of social determinants of health developed by Solar and Irwin  for the World Health Organization (WHO), which explicitly aims to not only guide empirical work, but also influence policy making . The strength of the framework lies in its inclusion of structural drivers of the social determinants, with political context particularly relevant in considering the impact of COVID-19 policies.
The aim of our study was to capture the burden of COVID-19 disease and socio-economic impact in households and communities on which there is limited data available, explore responses to the disease and increase understanding how these may influence vulnerability and wider determinants of health. We hope that this study and the learnings on the remote research method and tools that it employed will inform responses to the COVID-19 pandemic as well as other infectious diseases in vulnerable hard-to-reach populations.