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Blog by Tara Brace-John, Health Advocacy Advisor, Save the Children
I met Faduma on a recent trip to the Somali region of Ethiopia. She’s five years old, the youngest of six children in a nomadic Somali family. None of them have ever been vaccinated. Faduma’s father, who gave me permission to speak to her and to take a few photos, said that it has never been convenient for him and his wife to get their children vaccinated as they were always on the move; the day I met them, they were about 25km from the nearest primary health centre.
Meeting Faduma and her father made me question what it really means to reach the most vulnerable and hardest to reach with essential health services. Settled communities rely on the government for healthcare, education, utilities, and other services. Nomadic communities on the other hand are self-reliant and, fearing they will be taxed for their animals or forced to settle, extremely wary of any contact with state institutions. The border between Ethiopia and Somalia is rather porous, with nomadic families moving across it all the time, exacerbating the challenge of tracking and reaching them.
All this makes it tricky to come up with effective ways to reach nomadic families, to ensure they are immunised, and that they have access to other essential health services. But if we are to meet our commitment to leaving no one behind, it’s critical we find effective ways to reach nomadic families such as Faduma’s to ensure they are protected from disease outbreaks. Areas along the Somali border have had frequent outbreaks of vaccine preventable diseases, like the measles outbreak in May 2017. If communities aren’t vaccinated, they may inadvertently contribute to exacerbating outbreaks that weak health systems are just unable to cope with.
There have been various attempts by UNICEF, Save the Children and local civil society organisations to try to reach nomadic families. But generally, they have been short-term projects. The lessons learnt have not led to regional health systems being strengthened to sustainably address the needs of nomadic communities.
NOMADIC COMMUNITIES CAN BE REACHED
There are a few tested ways to reach nomadic communities. One, perhaps surprisingly, involves vaccinating their precious animals, which are valued and prioritised over everything else. There have been attempts to use the animal vaccine cold-chain to offer human immunisation services as well, including sharing information with communities on the importance of vaccines, schedules, and how and where to access services.
UNICEF has also worked with brokers and clan leaders to do a social mapping exercise in order to reach more nomadic families for polio campaigns. As part of this work, brokers and clan leaders were trained to pass on information on the importance of vaccines, immunisation schedules and locations where these services could be accessed.
SHIFTING OUR APPROACH TO REACH NOMADIC FAMILIES
In order to reach nomadic families with life-saving healthcare and immunisation, we could work with brokers to develop a schedule of market days and ensure that outreach services are extended to cover these locations. We could also collect mobile phone numbers of nomadic community members, which they use for trade, and use them for health promotion messages and information on when and where to access services. Nomadic families are increasingly buying products such as sugar, salt and soap, so outreach programmes could also target regular markets and shops they frequent. We could also produce posters and other health information materials for shops used by nomadic families.
There are many possibilities for reaching those, like Faduma, who are currently unreached. But despite the rhetoric about reaching those who are furthest behind, nomadic communities, such as Faduma’s, are rarely prioritised.
One of the ways to ensure that we reach those who are unreached could be for the government to provide high-quality health care to settled communities living in the same areas. This will build trust in the health system – and attract nomadic families to use them too.
Universal access to health can be achieved for settled and nomadic communities if governments invest sufficiently in their health systems and ensure that primary healthcare services are accessible to all citizens free at the point of use. That’s part of a government’s responsibility to its citizens. Where governments are failing to do this, civil society organisations often step in. But that doesn’t take away from the fact that governments should be doing it. Donors also have a role to play. It’s important to acknowledge that enhanced outreach programmes are more expensive to roll out – that the cost of reaching a relatively few nomadic people may be higher and take longer than reaching a settled community.
FROM RHETORIC TO ACTION
Action is needed at all levels:
The global health community must go beyond the rhetoric of leaving no one behind and truly hold themselves and the international community accountable for the health outcomes of the most marginalised communities.
Governments must find ways to engage and consult with nomadic and other marginalised groups on the best ways to meet their health needs.
Civil society organisations must be willing to go against the grain and challenge their donors and themselves on the need to prioritise the health needs of those who are unreached.
Until this happens, universal access to health will just remain a mirage for nomadic communities.
Until this happens, children like Faduma will continue to fall through the cracks.