By: 16 August 2017
Partnerships for progress in Somaliland

Safe Anaesthesia for Somaliland (SANSOM) drew together partners from across four continents to help Somalilanders improve their anaesthesia services.

Edna Adan  at  Bruao Hospital.  Photo credit Copyright Tim Bekir

Edna Adan at Bruao Hospital. Photo credit Copyright Tim Bekir

The global health community is slowly waking up to the huge inequality in access to anaesthesia services. Two thirds of the world’s population are without safe, affordable surgical and anaesthetic care, most in low-income countries. This represents a huge and growing global burden of untreated disease.

Somaliland is an impoverished territory in the Horn of Africa, presently in the grip of prolonged drought. A self-declared independent state, Somaliland remains unrecognised by the international community and consequently receives relatively little aid. Now peaceful, a ferocious civil war destroyed most of the health services, which Somalilanders are struggling to rebuild. Difficulties to be overcome include a lack of equipment, supplies, and skilled health workers and very few health facilities in rural areas.


A new anaesthesia workforce

New training courses in Somaliland have produced the country’s first batch of 32 qualified anaesthesia technicians. With very few physicians, the main providers of anaesthesia are technicians and nurses, as is common in developing countries. Somaliland’s newly qualified technicians have been deployed to hospitals around the county, where they often find themselves working in remote locations, with few resources, inadequate equipment and little support. The SANSOM project aimed to support and retain these non-physician anaesthetists who are crucial to the future of anaesthesia services in Somaliland.


Partnerships for progress

SANSOM planned to nurture the country’s new anaesthesia workforce by supplying them with appropriate equipment and continuing medical education that would help them to build their skills and to carry out their jobs effectively. To this end the project brought together a partnership of anaesthesia trainers, equipment manufacturers and funders from around the world.

Funding was secured from Safe Anaesthesia Worldwide (SAWW), a UK registered charity and the DAK, an Australian foundation. Both charities have an interest in cost-effective methods of providing affordable anaesthetic care in low-income countries.

Specialised equipment was supplied by Diamedica (UK) Ltd, a company that design medical equipment for use in low resource settings. The company had previously supplied equipment to Somaliland and were familiar with the conditions in the country.

A small portable anaesthesia machine (Diamedica Portable Anaesthesia or DPA02) was selected that could be easily operated and maintained by the anaesthesia technicians. This simple machine requires no electricity and can be used without compressed gases or expensive consumables, making it ideal of use in remote locations.

Each anaesthesia kit also included two oxygen concentrators, fitted with voltage stabilisers to protect them from damage due to voltage fluctuations, together with other basic essentials, such as a stethoscope, sphygmomanometer, laryngoscope, and a Lifebox pulse oximeter.


Continuing Medical Education

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Dr Mark Newton of Kijabe Hospital delivers a lecture to student attending the first SANSOM conference. Photo credit Copyright Tim Bekir.jpg

A three-day refresher course was organised by anaesthetist Mark Newton, a professor at Vanderbilt University USA. Prof Newton lives primarily in Kenya where he is head of the highly regarded nurse anaesthetist programme at Kijabe Hospital. Prof Newton and his team at Kijabe have been responsible for organising new anaesthesia training programmes in Somaliland and South Sudan.

A Continuing Medical Education (CME) conference was held at the Edna Adan Hospital in the capital Hargeisa and attended by a total of 34 anaesthesia technicians. Entitled Anaesthesia for the Mother and Paediatric Surgical Patient in Somaliland – an update, the programme included lectures, practical workshops and case studies.

Students were especially engaged by sessions on neonatal care and resuscitation using a sophisticated Laerdal simulator manikin, with clinical parameters controlled from behind a screen via a laptop. Feedback from those who attended the course was overwhelmingly positive, with many requesting that similar events be held annually.

During the course, pairs of technicians from ten hospitals selected by the Ministry of Health were given the kits of new anaesthesia equipment. They also received tuition on how to use and care for the new equipment by the manufacturer Diamedica.



Record keeping and data collection

A further important aspect to this project was the provision of electronic tablets to students with instruction on how to use them to keep patient records and capture perioperative data such as type of surgery, anaesthesia, complications blood loss/blood given and mortality. A data collection system called REDCap – the largest data collection system used in global health – is now being used to collect anaesthesia data in Somaliland for the first time. This data will be useful to improve the technicians performance and for evidence-based planning of future anaesthesia services in the country.

The tablets were also loaded with anaesthesia texts in order to serve as anaesthesia libraries, an invaluable resource for each technician that was eagerly received.


Countrywide significance

Just five years earlier there had been no trained anaesthesia providers in Somaliland, so this gathering of anaesthesia technicians represented a significant achievement for the country as well as for each individual involved. Being the first CME anaesthesia programme in the country’s history, the opening ceremony was attended by various government officials including the Minster of Health and Higher Education, and attracted the attention of national news media.


On the road

SANSOM convoy on the road distributing anaesthesia equipment.

SANSOM convoy on the road distributing anaesthesia equipment.

The three-day CME course was followed by an extensive road trip to deliver and install the new equipment at the recipient hospitals across the country. A convoy of four trucks was headed by no less than Edna Adan, the 79-year old founder of the Edna Adan Hospital who has dedicated herself to transforming medical care for women in Somaliland.

Edna Adan has called the SANSOM Project ground breaking. She said: “It is the first time Somaliland will have an anaesthesia machine and trained technicians in every region of the county. There has never been that. That is ground-breaking – it is a pioneering project.”



During the project and the distribution phase, further hospitals were inevitably identified that needed equipment and anaesthesia providers who were eager for training. Since the CME course, the charity SAWW has donated further equipment and there is clearly much more to be done. The SANSOM Project is a beginning, rather than an end.

A follow-up assessment of the impact of this project on local anaesthesia services will be conducted after six months and one year. This, together with analysis of the collected perioperative data, should provide evidence to help secure funding for further initiatives in Somaliland, and possibly similar approaches in other countries.

Data from the WHO and the World Bank suggests that significant morbidity and mortality may be averted at low cost by the provision of surgery in many low-income and middle-income countries.


Safe Anaesthesia Worldwide

SAWW works to deliver safe anaesthesia worldwide, wherever it is needed. Some five billion people lack access to safe, affordable surgery and anaesthesia, most in low-income countries. Lack of trained staff and suitable equipment are just two of the hurdles preventing universal access to anaesthesia.

SAWW works to overcome these problems and often collaborates in with like-minded organisations and individuals to avoid duplication and achieve cost-effective results.


For more information about SAWW’s work please visit the website

Watch this video:

Main picture caption: Training leaders Hosea Cheruiyot and Mary Mungai, left, oversee the first installation of Diamedica’s DPA02 anaesthesia machine. Photo credit Copyright Tim Bekir.jpg

Author: Carol Newman, Secretary, Safe Anaesthesia Worldwide


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