Somaliland’s healthcare is arguably one of the least developed anywhere in the world, this is due to many factors including cost, incompetence, and rampant corruption but this is not a story about the state of healthcare itself, this is about mental health in Somaliland and the people it affects.
In this report, we will focus on the laws and regulations that are in place to protect the mentally ill in Somaliland and the role of the government in ensuring the well-being of these vulnerable citizens.
Mental illness, in many cases, requires lifetime care. It is financially, physically and emotionally draining for the caretaker and the family but in Somaliland, the options for those who can afford any level of care is limited to sending their loved one to a facility for the mentally ill.
Those that cannot afford are forced to confine their mentally ill relative in a room more often chained and isolated or worse let them loose into the streets of Somaliland.
The level of care provided by the existing facilities varies where a handful have structured programs to care for their patients but unfortunately, the vast majority are nothing more than private prisons for the mentally ill.
One characteristic that both public and private facilities share is their lack of access to mental health professionals and proper medication to treat their patients.
There is no reliable data and basic information related to the mentally ill or mental illness is nonexistent in Somaliland. The most comprehensive report about the state of Somaliland’s mental health facilities and patients was produced by Human Rights Watch in 2015.
Read the Human Rights Watch report here
Somaliland government’s own Human Rights Commission produced a report back in 2015 and out of the 70 odd pages, only two pages are devoted to mental health facilities known as “Cilaaj” in Somaliland.
Read the Human Rights Commission report here
The section of the Commission’s report on mental health facilities has no data it does however briefly describe the abhorrent sanitary conditions of the facilities including broken washroom facilities that leak into patients’ sleeping quarters, flea and other insect infestation causing the patients’ skin irritations.
Medication’s has to be purchased by the patients’ family from outside but in many instances, privately owned facilities concoct their own potions from plants and other unknown sources and sell them to the patients.
Somaliland Quality Control Commission recently confiscated thousands of empty capsule that were reportedly intended to be filled with traditional medicine for the mentally ill.
The Quality Control Commission did not return calls about the shipment of empty capsules and there has been reports that it was released to its owners.
The privately owned facilities for the mentally ill are run out of nondescript homes located in the middle of neighborhoods with absolutely no government regulation or oversight of any kind and more importantly, none have no background in medicine and specifically mental health.
There are two categories of patients held in these private prisons for the mentally ill:
- Someone with actual mental health whose family cannot provide the round-the-clock care needed but can afford the boarding fees of these facilities.
- Someone whose family have placed them in these facilities for rehabilitation, often from drugs and alcohol.
Even though family members are aware of the conditions of the mental health facilities, unfortunately, the vast majority of them do not have an alternative.
The are numerous cases of abuse at the hands of caretakers at mental facilities, there has been even deaths that were never investigated, following is the story of one of those victims.
The Case of Abdillahi Mohamed Abdi
A family member described the mysterious circumstance surrounding the death of his younger brother who passed away in a facility in Hero Awr area of Hargeisa.
The patient, Mr. Abdillahi Mohamed Abdi had suffered a traumatic head injury as a child when he was hit by a vehicle. The accident left him with seizures that were under control by medication from Dr. Gaboose.
Mr. Abdi grew older and stronger; any lapse in his medication regiment resulted in psychotic episodes that his aging parents could no longer control, and as a result, sent him to a facility that cost them $160 a month.
Two weeks into Mr. Abdi’s stay in the facility, the family got a call informing them of the death of Mr. Abdi . The facility explained that Mr. Abdi has passed away in his sleep possibly from a heart attack.
It is worth noting that the facility did not employ medically trained staff at the time of Mr. Abdi ’s untimely passing and could not, with any certainty, be sure that the cause of death was a heart attack.
There was no investigation into the cause of Mr. Abdi ‘s death by the facility or government. According to his brother, despite his mental illness,
Mr. Abdi was in excellent physical shape and he cannot believe that he would die of a heart attack just two weeks of being placed in that facility.
No recourse for Mr. Abdi’s family. Case closed.
A Semblance of Regulation?
Committing someone to a mental institution has been incredibly easy in the past. Just pay the fee, point out the person and it is done.
According to many people we have spoken to for this story, including former residents, they described how shockingly easy to place someone in these facilities, pay the fee and point the person out is reportedly how these facilities operated.
The Ministry of Health and the courts got involved and instituted new requirements that a patient must be evaluated by the Ministry of Health, and under oath their tribal elders attest to the court that a patient needs to be committed.
This is the only process with which mental health facilities accept new patients.
This process is confirmed by multiple sources that have placed family members in facilities, and though this is a major step in the right direction, unfortunately, like many things in Somaliland, there is no actual law that codifies this workflow. There is no follow up inspection from the Ministry of Health who issue licenses for these facilities.
It is unclear if the Ministry of Health has any guidelines that help determine if an operator is qualified to run and operate a mental health facility.
Even more alarming is the type of medication some of the facilities are using. Here is a promotional video from Raywan Advocacy Mental Organization displaying an array of packaged goods where almost all are have suspiciously Arabic sounding names.
Raywan Advocacy Mental Organization which is large center for the mentally ill seems to be sketchy in its services. The poster below is advertising a Sheikh that has joined their team who will cure black magic, possession by Jinn, Haemorrhoids and tooth decay.
Sahan is one the largest mental health facility in Somaliland and is reported to relatively speaking, one of the best. There are programs that train patients in various skills such as sawing, electric work and even provide recreational facilities. However, they too are reported to isolate a patient upon intake until they understand their general behavior and will use detention when a patient refuses to follow directions.
Patients are allowed visitation once a week at Sahan to bring change of clothes and bedding and if several visits are missed, the facility automatically discharges the patient.
According to a family member who recently placed moved a relative from another facility to Sahan, the level of care provided in this facility is much better. There is a nurse who sees patients and helps them take their medication.
There are multiple charitable organizations that support Sahan in food provisions and clothing for the patients.
Who is Job is it to Protect the Mentally ill in Somaliland?
There is no actual legislation in Somaliland that protects the mentally ill and we are uncertain if they are covered under existing laws for people with disabilities in Somaliland but what is clear is that no one is actually responsible or has the mandate to protect this vulnerable group of Somalilanders.
One of the government officials we have spoken to is Ibrahim Khadar Saeed, the former Director of Prisons from the Ministry of Justice.
Mr. Saeed saw the link between mental health facilities and his ministry’s mandate and wanted to leverage its expertise in managing prisons to help craft a framework of legislation with the relevant stakeholders. His efforts were futile.
Speaking with Khadar Nouh for this story, he went on to explain that multiple government agencies are involved in issuing licenses for mental health facilities, including Hargeisa Local Government, the Ministry of Health and the Ministry of Religious Affairs and Endowments.
In explaining the obstacles that have so far prevented the government from robust oversight and legislation to protect the mentally ill, Mr. Saeed stated that there are powerful interest groups in the mental health business including the most prominent business owners and Sheikhs from Somaliland.
We have been unable to locate any policy or framework from the Ministry of Health that governs the mental health facilities and as usual from Somaliland government websites, the policy section of the Ministry’s website lists less than useful information.
The Ministry of Religious Affairs and Endowment seems to exercise some kind of regulatory control over private mental healthcare facilities and according to the Director General Mr. Adam Abdallah, the ministry is working on the creation of legislation to govern mental health facilities.
The Somaliland Human Rights Commission we cited earlier states that this is one of the ministries that are in charge of licensing such facilities.
According to the Human Rights Commission report, an unknown number of mental healthcare facilities use a combination of traditional healing and religious methods.
The use Quran is the only reasonable explanation that the Ministry of Religious Affairs and Endowments would be involved in mental health institutions.
The Director General of the Ministry of Religious Affairs and National Endowment Mr. Adam Abdallahrecently tweeted “The Ministry of Religious Affairs and Endowments will take action against religious centers (Cilaajyada [mental healthcare centers]) after we received reports of abuse”.
The Director General Mr. Adam Abdallah did not specify the nature of abuse and what action the ministry is planning to take and did not respond to questions about the actions he announced.
The Director General, Mr. Adam Abdallah also tweeted that the Ministry of Religious Affairs and Endowment will be administering a test to the owners of the facilities for the mentally ill to gauge their religious knowledge. According to Mr. Abdallah, this was decided in a meeting with the leaders of the mental health facilities of Hargeisa.
Once again, its unclear from the Director General’s announcement that they will be testing the owners on their knowledge of the Quran or how effective it is use is in mental health.
Additionally, it is unclear if the Ministry has plans to visit facilities to actually inspect the living condition of the mentally ill patients.
There is a pecking order among government agencies that supersedes mandate. The Minister of the Religious Affairs and National Endowment is one of the most powerful ministers in President Bihi’s cabinet.
So why would the Ministry of Religious Affairs and Endowment lend credence and validity to these predatory businesses who profit from the misery of the most vulnerable members of our society? It’s about business, and this might be one of the most profitable businesses in Somaliland.
Income streams are direct boarding fees from residents ranging from $100 to as high as $160 a month and vast sums that come by way of donations.
What is being done?
Aside from the Ministry of Religious Affairs and Endowments’ effort to register and test the operators, there are no efforts to create a legal framework for protecting the mentally ill people and regulate mental health facilities in Somaliland.
Somaliland’s meager national budget of several hundred million a year will not be enough if one were to argue a world class standard of care for the mentally ill in Somaliland but what is well within the government ability is not being done.
Legislation to regulate privately owned mental health facilities and ensure the wellbeing of the mentally ill in Somaliland is what is missing. The role of the Ministry of Health and Justice is what is missing.
According to a Ministry of Health official who would not speak on the record for fear of reprisal said “No one is arguing for a level of care that is equivalent to what developed nations spend on caring for their mentally ill, that would cost more than Somaliland’s entire national budget, but we have thousands of employees in the ministry and assigning a mere 100 to go and inspect these hell holes, make sure the facilities are fit for human beings. That small step alone will do wonders for these poor people”.
Contributors:
- Khadar Nouh is a multimedia journalist based in Hargeisa, Somaliland.
- Ilyas Abdi a journalist with Radio Ergo based in Hargeisa, Somaliland
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