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Making health budgets work for children


Communities in Somali Region, Ethiopia, came together to successfully campaign for much-needed increases to the region’s health budget.

The situation in Somali Region

Somali Region in Ethiopia is caught in a cycle of famine, drought and conflict resulting in the displacement of children and their communities. Families on the move lose access to food, water and security, in a region with some of the lowest immunisation coverage and highest malnutrition rates in the country. In Somali Region less than one in five eligible children receiving all basic immunisation and more than one in four children experiencing some degree of wasting as a result of malnutrition [PDF].

A child is almost two-and-a-half times more likely to die before celebrating their fifth birthday in Somali Region [PDF], than a child in the capital, Addis Ababa.

The health system cannot cope

Health services in the region are barely able to cope with the needs of settled communities and in no state to address the additional needs of displaced or nomadic communities.

For decades, more rural regions in Ethiopia have faced the brunt of inadequate public health funding. Underfunded health systems don’t cater to the needs of the poorest. Nomadic and displaced communities are the most marginalised and forgotten in Somali Region.  

Bad roads and weak infrastructure also make Somali Region a challenging place to live and work. As a result, the region does not attract trained health workers and suffers from a severe shortage of doctors, nurses and midwives.

There are only a limited number of health facilities at the primary health care level and they frequently run out of vaccines and medicines. People sometimes pay around 2000- 3000 birr (47-70 USD approximately) for public transport to reach health facilities in an emergency. Mothers often walk for many hours with their children to get them vaccinated and are often disappointed to find none available. An issue exacerbated by a lack of electricity and fuel to help refrigerate and transport vaccines.

The state of health facilities in Somali region is a reflection of the limited funding. Until the government involves people in its planning processes and commits to allocating more resources for health, the situation in Somali region is unlikely to change. 

The most vulnerable are being overlooked

To fully understand the extent of the resourcing problem and build a foundation for improvements we carried out a budget analysis. Our research showed that the needs of the most vulnerable groups - women and children, were largely ignored in health plans. It also showed that the health budget made no provision for the numerous nomadic and displaced communities scattered across the region, who ended up falling between the cracks in health plans.

Somali Region health budget

As part of our analysis of the federal and regional government health budget from 2013 to 2018 we identified huge gaps and bottlenecks in the allocations for Somali Region. These included:

  • The Somali government’s health allocation stagnated at 6.5% over the 5 years; yearly health expenditure was just $2 - $3 per person.
  • Allocations to health made by regional state and district cabinets were not evidence-based and did not reflect the needs at grassroot level.
  • Allocations for urban hospitals were prioritised over community-based primary healthcare, which was at odds with national guidelines.
  • Money allocated to health was repurposed at district level for other activities.

These resource gaps continued well into 2019, even though the Ethiopian government launched a package of interventions aimed at meeting the needs of rural and nomadic communities. Despite its aspirations, the programme remains critically underfunded.

Communities and officials come together to fight for change

We shared the findings with partners, officials and communities, using policy briefs, press releases, radio and tv broadcast to draw attention to the situation.

The community brought our data to life and joined calls for increases to the health budget.

Growing engagement allowed us to train communities in ways to help assess different aspects of health service performance - such as drug availability and waiting times. There were strong correlations between problems identified by the community and the resource gaps identified by us.  We shared these findings with district health planning and budgeting officials, who were determined to use this information to push for increased health allocations.

Mr. Hassen Hussein, Deputy Head of Somali Region Finance Economic and Cooperation Bureau

Mr Hassen Hussein, Deputy Head of Somali Region Finance Economic and Cooperation Bureau

As the global COVID-19 crisis spread, local officials and religious leaders used the pandemic to stress that a poorly funded health sector crumbles under shock and urged the government to financially sustain routine immunisation and other key child survival interventions whilst also addressing the pandemic.

Campaign success

Finally, in 2020/2021, the regional council raised the yearly health allocation from 6.5% to 10.7%, the highest share ever of the total budget. With an additional USD 2.5 million allocated in support of the COVID-19 response.

In a testament to the months of continuous engagement and coordination between communities and officials, Mr. Hassen Hussein, Deputy Head of Somali Region Finance Economic and Cooperation Bureau, commented: 

“I saw for the first time that the health bureau strongly defended its budget proposal during the regional council’s budget hearings and debates sessions”.

The regional government also publicly communicated the new allocations for the first time. This sets a new precedent for transparency and accountability critical to ensuring future allocations and that existing allocations do not decrease.

Next steps

As we call for the regional government to maintain the new budget allocations and use resources more efficiently and effectively, we are also partnering with child parliaments in demanding the right to health for the most marginalised children. We’re also supporting efforts for greater health funding for women.

Civil society in Somali Region has shown the power of community voices and how budget advocacy can bring together communities and decision-makers to improve budget allocations for health.

We continue to work with civil society, community champions and government officials to ensure that the Somali health budget works its people.