Far-Reaching Integrated Delivery (FARID) Project

The FARID project follows three principles in project implementation: (i) community participation, (ii) innovation in data and mapping for precision of locations, and (iii) integrated services responsive to community needs. The project includes an extensive demand creation and community engagement component to build the trust of the priority communities and improve their health-seeking behaviour. At the centre of this work is the health camp model, which considers social, structural, and gender barriers prevalent among the populations living in inaccessible areas. The project design was informed by feasibility assessments, is adaptive to changes in the context, and is guided by standard humanitarian principles (humanity, independence, impartiality, and neutrality).

The health camps are mobile health facilities, moving around districts to provide families with vaccinations for polio and other infectious diseases, maternal health services, nutrition screening and supplements, and primary health consultations. These camps are tailored to address each community's specific needs and aim to re-establish sustainable health systems that will continue providing primary health services on a routine basis. Each health camp is planned for five consecutive days, repeated monthly. Access to these areas is facilitated through negotiation with community leaders, clan elders, and relevant non-state actors.

Specifically, in response to varying levels of insecurity within the project' targeted districts, FARID project operationalised a rapid and intensive scale-up of immunisation services following a phased approach. Two districts (Beledweyne and Xarardheere) were the first pilot districts in March 2023, and the remaining districts were reached progressively through clan-led access negotiation approach. Before initiating health camps, with collaborative support from other consortium partners and other actors, Save the Children gathered contextual information about each district to help design macro-plans. Simultaneously, clan elders mediated access through a negotiation process that involved three successive roundtable meetings. Upon securing the green signal for access, community-led microplanning was initiated, followed by a community-guided recruitment process and sourcing of other project inputs.

The model is delivered through partnership with local organisations able to operate in areas controlled by non-state armed actors. Namely, Save the Children engaged two local non-government organisations (NGOs) - Development for Humanity and Wardi Relief and Development Initiative (WARDI) - to set up hubs in the main urban centres of the respective districts. The main actor was then linked to these local partner NGOs, who worked with the community to identify locally available resources to set up these hubs and implemented the project. These hubs provide a base where mobile health teams stored their supplies, organised their health camp missions, and replenished vaccines and other supplies. All the consortium partners maintained a low-profile, monitoring the security situation and ensuring contingency plans to safeguard project personnel and assets, along with continuing coordination and communication with community leaders. Through coordination with the ecosystem of partners, the project team closely monitored emerging issues and proactively mobilised necessary support for effective responses to any urgency.

The collaborative project team also conducted a mapping of the existing health infrastructure in the target districts and established coordination links and referral pathways to complementary services not offered by the health camps. The team also worked together with Humanitarian Dialogue, the coordinating NGO, along with local communities through community health committees to promote access to, and utilisation of, the health camps.

Immunisation and Vaccines, Polio, Health, Nutrition

Decades of conflict, political instability, and limited infrastructure left Somalia facing significant challenges to offer consistent and equitable health services, especially for child vaccination. Data (2020) reveal alarming vaccination gaps, with 60% of children receiving no vaccinations, and only 11% completing required vaccines. An estimated 1.15 million children remain unvaccinated, half of whom reside in inaccessible areas whose population is largely rural and remote, with livelihoods more fragile than those in accessible or government-controlled areas. Their needs are further exacerbated by the global economic recession, the impact of COVID-19, climate change, and food price inflation, amidst diminishing oversees remittance and donor funding.

Through informal discussions with community members and parents/caregivers on why children are not vaccinated, the FARID team observed three recurrent themes: (i) lack of health facilities, (ii) safety concerns, and (iii) opportunity cost.

From March 2023 to March 2024, FARID partners visited 1,412 high-risk communities in Somalia that face significant or total barriers to healthcare, reaching over 530,000 people with primary health services. The programme and its partners vaccinated more than 150,000 children with oral polio vaccine (OPV) and over 280,000 with routine immunisations, including the inactivated polio vaccine (IPV), the anti-tuberculosis Bacille Calmette-Guérin (BCG) vaccine, the pentavalent vaccine, and the meningitis C vaccine. Partners have also identified more than 150,000 children who have never received any kind of vaccine through this initiative and conducted more than 123,000 maternal health consultations, more than 136,000 nutrition consultations, and more than 236,000 general medicine consultations.

Occasionally, the teams had to suspend services owing to renewed threats of insecurity or active conflict between government forces and Al-Shabaab. In June 2023, an immunisation volunteer team, consisting of four local NGO staff, was ambushed by Al-Shabaab in Qarsooni villages, Beledweyne district, Hiran region, Hirshabelle state. These team members were held hostage for 2 weeks before they were released through community-led negotiations involving
local partner WARDI. The disruption lasted for about a month before routine immunisation and other services resumed, and the team could again reach zero-dose children in the affected areas.

The lesson learned through this incident is that trust building and adherence to mutual agreements with elders and acceptance from the community are critical to ensure safe and successful project implementation. It also pointed to the need to focus on recruiting individuals who can navigate local dangers, effectively communicate, and build relationships with the communities.

Other lessons learned include:
 

• Clan elders' engagement was critical for project planning, implementation, and monitoring.
• Delivery of an integrated primary healthcare package created demand for service and community trust.
• Having local community-based organisations as implementing partners was the key for reaching the inaccessible population.
• Building strong relationships with local stakeholders and community leaders helps negotiate access to inaccessible areas and garner necessary support.
• Collaboration ensures comprehensive response to supply shortages or capacity gaps.
• Flexibility and adaptability to unforeseen events (e.g., natural disasters or security incidents) helps mitigate disruptions and maintain service delivery.
• Alternative recruitment strategies and leveraging existing expertise (e.g., by transferring qualified personnel from nearby areas) help overcome limited capacity.