November 2004

The International Policy Institute
King's College London
London WC2R 2LS
For further information, please contact:
Tel: 44-207-848-1432
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Executive Summary

Study objectives and focus

This study explores available options for providing welfare functions in so-called `failed state' situations. It focuses upon the innovations and entrepreneurial initiatives of the Somalis to date, and considers ways that these impact directly and indirectly upon the provision of welfare, principally health care, now and in the longer term. The report also assesses the ways that the international community has responded to date to such initiatives, and ways that it might do so in the future.

In exploring such options, the study's researchers held extensive discussions with representatives of the Somali diaspora in six countries, including the United States, and also with Somali elders, businessmen and local authorities in Somalia, itself. Equally as relevant were discussions held with government authorities in countries where the Somali diaspora reside, and a range of multilateral organisations that worked in Somalia.

Chapter 1: Introduction

1. Five key issues need to be better appreciated when working in `failed state' situations:

a) so-called `failed states' are about the collapse of conventional governance structures, and not necessarily about the collapse of social structures. The latter can be very resilient and innovative in dealing with issues of livelihoods and development;

b) conventional perceptions of Somalia remain influenced by the horrors that occurred in the immediate aftermath of the civil strife in the early 1990s. Greater awareness is needed about ways that early events affect perceptions about the present and future;

c) the changing nature of migration and asylum seeking is leading increasingly to a phenomenon of transnationalism in which Somalis with dual nationalities, eg, USSomalis, assimilate in their adopted countries, but retain their national identity in their countries of origin;

d) the nature of innovation is often missed or ignored by the international community in Somalia, resulting in parallel development activities that all to rarely intersect;

e) the inviolability of family remittances has been a basic assumption in much of the remittance literature, or, in other words, it is generally assumed that the diaspora will always be reluctant to try to guide the way that remittances are used. There would seem to be far greater flexibility in the attitudes of remittance providers than this assumption would suggest.

Chapter 2: The Global Perspective

1. Only in the last few years has the remittance phenomenon received the sustained international attention it deserves - the G8 put remittances on its 2004 agenda, and together with the World Bank and IMF, along with a number of donors, these groups and organizations are focusing on their development potential.

2. Remittances have comprised the `second largest source of net financial flows to developing countries'1 over the last decade. Donors have thus begun to pay more attention to this phenomenon, not only because an improved understanding of these flows would greatly facilitate donor programming and needs assessments, but also because of the collective investment potential of remittances.

3. While data is incomplete, studies undertaken indicate that between 25 and 40 per cent of all families in Somalia receive remittances.2 One study estimates that total remittances used for household purposes may reach $360 million annually, which equal 22.5 per cent of total household income, while the same study noted that the gross remitted annually is between $750 million and $1 billion.

Chapter 3: Somalis helping themselves

1. The Somali diaspora is not homogenous, but has generally played a major role in determining the basis for livelihood support, in issues of politics and security, in capital investments as well as in the development of social services, civil society and social welfare organizations and businesses.

2. The diaspora contributes substantially to development in Somalia, but this development is largely unplanned. This has led to unnecessary duplication of effort and waste. One reason for this is the lack of national goals, but another is the very localized nature of diaspora contributions.

3. Key problems in the health sector include the chronic lack of qualified professionals, lack of professional governance and inadequate resourcing. Nevertheless, there are a variety of developments worth noting, including the proliferation of private clinics, pharmacies and hospitals as well as the emergence of cost-sharing schemes, regional health boards and medical associations. There is very little information about the private sector initiatives, and to date there has only been limited collaboration between them and international organizations.

4. Diaspora support for health appears to take two main forms: i) family remittances to meet needs for common and emergency medical treatment; and ii) groups in the diaspora mobilize funds in support of health facilities, principally hospitals.

5. In the absence of government, the private sector has taken on certain roles in health provision, including the supply of drugs through pharmacies and the provision of medical care from the diagnosis and treatment of common ailments to midwifery and complicated surgery. The focus of private health care is almost wholly curative, with only limited involvement in primary health care and no involvement in preventative health care or sanitation.

6. Access to health services for the poor and rural populations is uncertain. It relies on clan and religious obligations, remittances through extended family network, and conventional charity through local non-governmental organizations.

Chapter 4: International aid efforts

1. In Somalia, there are two categories of international assistance. One is the western institutional approach reflected in the Somalia Aid Coordination Body (SACB), and the other is Islamic charitable assistance that operates outside the SACB framework. The former reflects the procedures and structures of all inter-governmental organizations (IGOs), all OECD donors, and the majority of international non-governmental organizations (INGOs).

The latter is paradoxically more blatant and more subtle. It is more blatant, for incidents of charitable giving can have clear and overt political objectives; and more subtle in that a considerable portion of Islamic assistance is provided in ways that blend with and support local customs and institutions, and reflect more of a culture of empathy than sympathy in dealings with recipients. Islamic assistance in Somalia is not purely `humanitarian', but forms part of a social programme, mostly associated with the moderate Al Islah movement, which seeks to promulgate Islamic practices and values in Somalia.

2. The international community plays a vital role in the health care of Somalia, and clearly is the only consistent source of public health care [PHC] available to the Somali people. In addition to PHC, the international community supports the provision of health care in ways that directly and indirectly affect Somalis' own health care initiatives. Somali health institutions directly benefit from institution and capacity building programs and the development of health codes and standards. Indirectly, international initiatives to establish demographic information and data collection systems, to facilitate the flow of remittances in ways that are transparent, and to develop public employee support schemes and returnee programs all impact on the health sector.

3. Despite these efforts, the international community has given little systematic thought and analysis to strategic approaches that could foster and promote an indigenous health care system in Somalia. The international community has to consider the strategy policy gaps that exist in its present health care approach, its inadequate interaction with Somali culture and structures, its lack of substantive coordination in the health sector and the lack of linkages between Western approaches and other approaches, e.g., those of Islamic charities.

4. Islamic charities appear to be more effective at interacting with Somali social networks than Western aid organizations. Beyond a common religion, there are administrative practices as well as consultative approaches that enable these charities to become more engrained and more influential in the development initiatives.

Chapter 5: Somalis look to the future

1. Interviews with over 300 Somalis outside and within the country covered the following topics: a) health care services in Somalia; b) health care infrastructure; c) security; d) the establishment of sustainable health services; e) payment systems; and f) quality control: a) currently, health care services are principally concerned with curative matters.

While respondents accepted that a future health system is most likely to be based on private provision of care, they felt that a combination of religious and clan obligations, remittances from extended families and national and international charities and donors would have to cover the needs of the poor;
b) health care infrastructure from the Somali perspective suffers from three general weaknesses: i) the quality of professional medical staff; ii) the quality of medicines; and iii) the types and standard of equipment;
c) security was frequently mentioned in a clan context, described principally along three lines: a) security of property and health infrastructures; b) security for medical staff; and c) security of access. Clan intervention, however, was double-edged, often as disruptive as it was positive. It was felt that the ways the business community operates could be as effective as any in terms of ensuring security.
d) the establishment of sustainable health systems could principally be on four financing options: i) charitable investment; ii) cooperatives; iii) capital investment; iv) a combined scheme based on share options in an insurance scheme.
e) systems by which Somalis would pay for health services might include i) clan and family obligations, ii) zakat1 and related religious obligations, iii) payment innovations including insurance systems and micro-credit - aspects of which have cultural bases for doing so, eg, hagbad or sholongo;
f) to enhance the quality of health services, respondents felt that greater training, advocacy and education, and regulation were essential. Ways to ensure equity and access to health care services for the poor and for rural areas were also considered important.

Chapter 6: Implications for the future

1) The study offers important options and approaches for enhancing Somali health care, despite the absence of a government structure. to maximize the benefits arising out of these options and approaches, the following five sets of recommendations should be considered:
a) Fill the information voids. There is a considerable lack of information in many key areas that inhibit the development of effective Somali-based welfare systems. These gaps need to be filled, and hence require:
i) Comprehensive mapping and analysis of types and levels of health services available throughout Somalia; ii) Capacity assessment. Establish data-base on number and quality of medical practitioners in Somalia and diaspora. iii) Coverage and utilization. A survey of the coverage and utilization of health services; iv) Payment systems. Study on alternative payment systems for health care coverage, including prospects for micro-financing and micro-insurance schemes.
b) Promote dialogue. Somali respondents appeared very responsive to a variety of entrepreneurial ideas as well as suggestions about ways to deal with the health needs of their families and communities in Somalia. There are, however, few opportunities to discuss such `visions' with experts, and little incentive for the diaspora to think in different ways. There is a clear need to promote dialogue along the following lines:
i) Community discussions. Through various diaspora modalities, such as mosques, community organizations, the internet, and the media, discussion could be facilitated on the various health initiatives that could work in Somalia;
ii) Money transfer companies and social responsibility. Discussion could be facilitated between host governments and key money transfer companies on ways to promote Somali health care;
iii) Medical associations. Facilitate discussions with Somali medical associations on training needs and health standards;
iv) Use media in Somalia and in diaspora communities. International (e.g., BBC), national (e.g., Somalia-based radio) and host country media (e.g., local radio) could be used to generate discussion on a vision for health care in Somalia;
v) Promote Islamic NGO-SACB discourse. SACB should take lead in actively promoting discussions and exchange of information with Islamic charities in Somalia.
c) Facilitation. The theme that underlies all the report's recommendation in general is the need to work with the Somali diaspora and Somali civil society in ways that aligns the initiatives of Somalis and the work of the international community more closely. The recommendations noted below are also consistent with that theme. i) Analysis of support mechanisms. Following from 1.d, above, analysis to determine ways international community can support Somali-run health care initiatives. ii) Review tax support schemes. Review of possible tax incentives to promote continued flow of remittances; iii) Promote regulatory frameworks and codes of practice. Intensify existing efforts at regulatory framework development with emphasis upon country-wide agreement.
d) Training. As in so many other aspects of Somali life, the issue of training and education looms large, both among the diaspora and in Somalia.
i) Refresher and retraining courses for diaspora medical practitioners. Develop initiatives to strengthen the professionalism of doctors, nurses and health care administrators in the diaspora;
ii) Refresher and training courses for Somali professionals in Somalia. Develop initiatives to strengthen professionalism of doctors, nurses and health care administrators in Somalia;
iii) Training in data collection and statistical analysis. Expand initiatives presently underway, with emphasis on uniform practices and systems.
e) Pro-active strategy development. i) Inter-institutional strategy development. Develop an overall strategy for the provision of Somali health care, based on recommendations outlined in 1 - 4 above;
ii) Country comparative analysis. Comparative analysis of programs with the diaspora in other countries designed to fund health care and ensure safety nets for the poor, e.g., Ghana;
iii) Pilot projects. In parallel with an inter-institutional strategy, there should be a small number of health care pilot projects - expanding on existing projects or developing new projects - in which the main components of an integrated strategy could be tested. These main components would `test' some of the key elements noted in recommendations 1 - 4.

Acknowledgements

Research projects rely to a very significant extent on the good will and interest of outside participants who give their time, perspectives and experiences to the exercise. This study is no exception. Certainly the many Somalis who participated in this effort, individually and in groups, in Denmark, Great Britain, Italy, Kenya and the United States as well as in Somalia have been key to this study. The authors would clearly like to express their most sincere gratitude to the many Somalis who so willingly and with such enthusiasm helped us.

The United Nations Development Programme in Somalia has been consistently supportive, and special thanks goes to the UN's Resident and Humanitarian Coordinator, Max Gaylard, as well as his colleagues Abdusalam Omer, Gina El Koury and Regina Ndonyo. Various research institutes, such as the Danish Institute for International Studies, were very helpful, as were many members of the Somali Aid Coordination Body in Nairobi, in particular Dr Imanol Berakoetxea. At the same time, many UN agencies in Nairobi and in Somalia opened their doors to the study's researchers, and here again we owe them our thanks. We owe particular thanks to also Saeed Ahmed (Penha), Dr Adan Abokor (ICD), Abdirahman Raghe (WSP International), and Pat Johnson (Ec) for their help.

It is dangerous to mention particular individuals when so many individuals deserve our gratitude. And yet, the authors in this instance feel a special debt to Cerstin Sander and Manuel Orozco, who took so much time to share their own research findings and to guide us through many aspects of our work. Additional thanks as well to Dr Andre LeSage and Nisar Majid.

Finally, all to often large governmental bureaucracies are accused of failing to be innovative and unwilling to go beyond their conventional standard operating procedures. This certainly has not been the case for the United States Agency for International Development, which has proved to be consistently supportive in what inevitably has been a speculative piece of work. to USAID in terms of its substantive support and to Macfadden & Associates in terms of its administrative support, our sincere thanks.

Chapter 1: Introduction

I - Purpose and objectives

This study explores alternative approaches to the provision of welfare services in `failed state' situations. It has been funded by USAID as part of its continuing efforts to explore innovative ways to assist those in need. It examines how welfare services, normally the purview of governments, can be provided in the short term without the direct support or indirect regulatory authority of government, and with the commitment of traditional social structures, the private sector and nationals who live within and outside the country. The purpose of this study is not to judge the respective merits of alternative systems, nor to compare such alternatives to conventional government systems. Rather, the aim is to suggest indigenous options that might provide welfare functions when conventional governmental modalities are not available.2

This will be tested in the context of Somalia, a country which has had no formal national governmental structures nor official national authorities to provide health services since the collapse of government in 1991.3 As Chapter 3: Somalis helping themselves explains, there are various Somali-driven initiatives that provide health services, from private specialist clinics to relatively well-established `teaching hospitals'. At the same time, it is also the case that over the last decade the international community - through NGOs as well as UN agencies - has been the principal provider of public health care, including extensive vaccination campaigns and various types of medical facilities such as Mother/Child Health Centers (MCHs).

The proposition of this study is underpinned by three inter-dependent factors. The first is that remittances from the Somali diaspora might be an effective source of funding to supplement and support, if not initiate, some form of adequate health coverage in Somalia. A second assumes that the Somali business community - much heralded for its entrepreneurial capacities - could support such systems if appropriate incentives could be found. The third concerns the stabilizing factor inherent in Somalia's clan and kinship structures, which assures a modicum of regulation, security and equity within and across clan structures.

II Study challenges

Five additional, perceptual challenges are worth noting from the outset: i) assumptions about so-called `failed states'; ii) conventional perceptions of Somalia; iii) the nature of migration and asylum seekers; iv) the nature of innovation; and v) the inviolability of family remittances.

i) `Failed states'. One key challenge of this study has been the perspective that many have about the nature of the `failed state'. to many, the term connotes a complete vacuum of authority and opportunity. The authors of this study, however, find conceptual difficulties with the term `failed state'.4 In practice one is really referring to the collapse of effective government, or of authorities that can provide conventional security, governance and functional services. There is an emerging case for looking at `failed states' not just as collapsed formal government structures, but also as part of the dynamics of rapid societal restructuring.

There are few instances of complete state collapse, and where they have occurred, most have taken place in the immediate aftermath of inter or intra-state conflicts. Nevertheless, even in these relatively few situations, alternative social organizing structures and functional institutions emerge, based on tribal, kinship and clan connections. These can also include agricultural and trade communities, and are not normally confined to standard geo-political state boundaries. They often `spill across' borders. These structures also provide important stabilizing and livelihood functions in the absence of conventional authorities. The challenge is, therefore, to convince policy-makers and planners to consider the range of possible opportunities in `failed state' situations to enhance livelihoods and welfare needs.

ii) Perceptions of Somalia. In the post-cold war period, Somalia can lay claim to the title of the most protracted example of state collapse, if not in the post-colonial period. Given the conventional perceptions of `failed states' noted above, it is not surprising that the predominant view of Somalia by those working in western governments, NGOs and multilateral institutions is one of anarchy, violence and economic and social collapse. In so many respects this perception fails to take into account the remarkable stability that exists within a country that lacks conventional military, police and judicial authorities.

Today, many officials know Somalia only for humanitarian reasons. The United Nations asserts that continuing grave human rights violations, chronic drought, food insecurity, and sporadic violence constrain development and prevent international aid workers from accessing many parts of the country. According to the UN, 750,000 Somalis are `chronically vulnerable'5, out of an estimated population of 7 million.6

Yet at the same time, since the state collapsed, statistics have been difficult to compile given the insecurities on the ground, the lack of regular and reliable data collection, and because up to half of the population is nomadic. In fact, Somalia has not been included in the United Nation Development Program (UNDP) global Human Development Index since 1997 due to this problem, even though in recent years data collection in some sectors has improved.7

According to UNDP, there is an absence of comprehensive baseline statistics. Information on population movement and displacement or seasonal migration patterns is weak. The informalization of the economy makes economic analysis particularly difficult and the extent of privatized services such as education is unknown. As data collection is dependent on the quality of access, there is a bias in the volume and quality of data collected to areas where there is better security.8

Not only do estimates of the population in Somalia vary considerably, but so to do figures for the Somali diaspora, as well as for how much money is remitted into the country annually. Estimates of the size of remittances going into Somalia on an annual basis range from $500 million to a billion dollars. The lack of accurate information on remittance flows precludes an accurate understanding of family livelihoods and coping mechanisms in Somalia.

The reality is thus far more complex. In fact, such perceptions coupled with the lack of baseline data overlook the fact that humanitarian crises have with some notable exceptions been relatively infrequent and geographically isolated over the past decade. This is by no means to suggest that Somalia is a development or Libertarian exemplar. And yet, one has to acknowledge that there has been impressive economic growth in important though isolated sectors. The main characteristic of this growth has been Somali enterprise. The much vaunted telecommunications system, abattoirs and chilled meat processing plants, radio and television stations, airline companies as well as medical clinics, hotels and restaurants and even a Coca Cola plant, are all illustrative of this dynamism.

iii) Nature of migration and asylum seekers. European countries in particular seem seized with the issue of `safe return', or promoting opportunities for migrants and asylum seekers to return to their countries of origin.9 This focus ignores the reality of 21st century migration, namely, that asylum seekers and migrant workers as well as a growing percentage of humanity at large will become the new-age Phoenicians, flowing back and forth periodically between home and host countries, having cultural, professional and ethnic affinities in several parts of the world - both North and South. They are truly `transnational'. The `export' of at least one family member to work abroad and support the family back home has become a coping mechanism for many families in developing countries.

iv) The nature of innovation. An important challenge also implicit in this report concerns the nature of innovation. For many in the relief and development world, prime attention is given to efforts to assess the needs of the poor, vulnerable and disaster or emergency-affected, and to what are described as `coping mechanisms,' or the survival strategies of the poor and those perceived as vulnerable. Yet not enough attention is paid to the innovations of populations affected by institutional collapse, that is, how they provide for a range of their needs. A perfect example is the development of the Somali remittance system, established by Somalis to help Somalis survive and often prosper, whether they be in refugee camps, urban or rural areas. The remittance house phenomenon in Somalia took place with only belated recognition of its importance by the international community, and thus synergistic opportunities that would combine the efforts of the international community with Somali innovations have frequently been lost.

v) Inviolability of family remittances. Finally, most development economists and government policy makers involved in remittances at the global level all agree that one should not touch family remittances. In this study, the researchers have found more flexibility concerning this fundamental point, at least in the case of Somalia. The diaspora spoke in terms of adjusting their contributions if they felt that they were being abused. Many also showed keen interest in exploring different ways of providing assistance if such methods would result in more efficient use of their contributions.

III Methodology

1) From a methodological perspective, findings were principally dependent on interviews with four constituencies: i) the Somali diaspora, including representatives of money transfer houses; ii) representatives from host governments concerned with development, foreign policy, asylum, remittances and integration policies; iii) international organizations concerned with development and humanitarian aid; and iv) Somali nationals living in Somalia.

i) Somali diaspora. Interviews were conducted with approximately 300 Somalis from diverse professional, cultural, ethnic and geographical backgrounds. As discussed in Appendix 3, these interviews took place in Denmark, Great Britain, Italy, Kenya, Switzerland and the United States. Researchers conducted semi-structured interviews on the nature of the remittance system, and the provision of health care in Somalia. Researchers also discussed with respondents their experience of health services from other parts of the world and their potential application in Somalia, such as mobile clinics, commercial incentives and insurance schemes. A range of ideas was explored, the key ones are noted in Chapter 5: Somalis look to the future. While some of these ideas had already been utilized in parts of Somalia, the focus for the discussions was on their wider applicability.

ii) Host governments. In four out of the six countries covered by this study, researchers held discussions with representatives from government institutions who were responsible for asylum, remittances, foreign affairs and development. In all four, there has indeed been a recognition of the important role remittances play in Somalia, and all have been making some efforts to enhance the development aspects of remittances. In general, the researchers found government and non-governmental actors receptive and interested in the output of this study. Yet despite these efforts, thus far they have primarily been of an ad hoc and exploratory nature. to date there has been little consistent effort by these same host governments to look at potential inter-relationships between remittances, asylum seekers and migrants, and the impact that both might have on issues of development. In other words, officials in development and foreign policy functions rarely relate to those involved in `home office', or domestic policy priorities.

iii) International organizations. Multilateral institutions such as the World Bank also recognize a link between remittances and overall development trends. While acknowledging the importance and enormity of the former, exactly how remittances might relate to development priorities and programs still requires further study and analysis. From the perspective of the World Bank, which has made remittances a priority at the global level, it is at the same time wary of encouraging any initiative that might negatively impact a wellfunctioning system that supports livelihoods and local investments at the family level. The Bank's reluctance may also reflect a recognition that many governments whose citizens are in receipt of remittances have formal and informal ways of anticipating their effects.

iv) Somalis in Somalia. The security situation during mid-2004 did not allow for the relatively extensive travel in Somalia which had been planned. no interviews were conducted in the South, but a representative of the study team was able to spend one week in Somaliland. Somalis from other regions of Somalia were interviewed in Kenya. Researchers were also able to undertake interviews of the diaspora in more countries than originally intended.

2) Literature review. The researchers undertook an extensive review of the burgeoning literature on diasporas and remittances as a global phenomenon, and the nexus between diasporas, remittances and development. This is discussed in Chapter 2: Global Perspectives. The diaspora and remittance literature that pertains to Somalia and the Somalis, however, is relatively scant. That which does exist focuses principally on asylum issues in host countries, although there is an emerging literature on remittances and general development in Somalia. Nevertheless, many remittance-related and health care initiatives that have been studied by academics and policy-makers in countries such as the Philippines, Mexico, Bangladesh and sub-Saharan Africa have potential relevance for Somalia. This includes locally maintained health care systems, micro-insurance and micro-finance schemes, self-regulated professional associations and even government mechanisms to foster the flow of transparent money transfers.

IV Outline of the report

The following chapter, Chapter 2: Global Perspectives, defines the nature of remittances, the impact that they have had elsewhere and, significantly, how aspects of these experiences could help inform our understanding of the phenomenon in Somalia. It is with this in mind that Chapter 3: Somalis helping themselves explores initiatives that Somalis have recently undertaken that have had significant impact on the economy and social services of the country. If there are positive aspects for Somali society from these types of Somali-driven initiatives, it is important to determine if and how the international community links into them. Chapter 4: International aid efforts, therefore, investigates the degree to which the international community supports such initiatives, undertakes activities that do not impact on these initiatives at all or in effect operates separate but occasionally intersecting activities. Chapter 5: Somalis look to the future takes the implications of the first four chapters, and `tests' them in terms of health care. As Somalis look to their own situation -- now and in the future - to what extent can they envisage what has been described as `the Somali way' leading to enhanced health care services? to what extent do they see a way forward in this one crucial welfare area, in which governmental support and regulation are not available?

Based on the issues raised in Chapter 5, Chapter 6: Implications for the Future provides conclusions and recommendations that should be considered if the positive implications of a `Somali way' are to be linked into the support provided by the international community. In so doing, this final chapter also considers the implications for coordination between Somali and international initiatives, issues of accountability and the implications of these initiatives for future Somali governance.

Chapter 2: The Global Perspective

Remittances: How do they work?

Only in the last few years has the remittance phenomenon received the sustained international attention it deserves. In 2004, the G8 put remittances on its agenda10, and together with the World Bank and IMF, along with a number of donors, these groups and organizations are focusing on their development potential. Moreover, informal remittance transfer systems have been receiving negative attention, as governments attempt to comply with the regulations imposed by the Financial Action Task Force (FATF) to prevent money laundering and terrorist financing.

The impact of remittances on developing states is indeed significant. In 2000, remittances from abroad comprised more than 10 per cent of the GDP of a number of developing countries.11 In 2003, migrants sent close to $100 billion to developing countries, while estimates reckon that `informal and under-reported flows suggest the actual figure may be two or three times as high'.12 Nevertheless, even the formal figures represent a large percentage of international financial flows and far outweigh Official Development Assistance (ODA).

Some researchers estimate that they may even approximate half of foreign direct investment.13 Remittances provide a vital lifeline to poor families in home countries. Funds remitted are used primarily for daily subsistence, but they are also used for loan repayment and investments, and in some instances, collective remittances are used for development projects. The general pattern is that money is sent from developed to developing states, but often flows go from neighboring states or even within a state. Typically they are received in urban rather than rural areas, though the spill-over from the urban often reaches rural relatives. In general, these flows are more stable than other types of capital flows, and in times of crisis at home, they tend to increase. Remitters are typically low-wage earners, who tend to send a large percentage of their income home. Even prisoners have even been known to remit a portion of their very meager prison earnings to their families.14

The global average transaction is estimated at $250 - which is sent on a monthly basis from financial institutions or money transfer companies - the latter can be any type of small business, such as a corner grocery store or an internet caf�. The US banks' share of remittance transfer business is extremely small, with the bulk of their services dedicated to Mexico. Even concerning Mexico, bank involvement is estimated as low as three per cent.15

Money transfer services such as Western Union are also popular, as are the informal hawala 16 shops. At the receiving end, there is also a mix of formal and informal institutions, and often the latter act as banks through extension of micro-credit and other forms of loans. Both the informal and the formal transfer services can be found in host and home countries, and interact with each other regularly. While the cash itself rarely moves, a number of creative accounting practices are used to ensure that the flow continues in each direction.

Globally, the average cost of a transfer is about 13 per cent of its value. The informal houses are usually cheaper, charging between three and five per cent, while some earn their fees through playing with exchange rates.17 People choose a service provider because of `familiarity, trust, proximity, reliability, and awareness'.18

In the United States, money transfer services are regulated in most states. They are categorized as `nonbank financial institutions', and have their own licensing and bonding requirements in each state. At the Federal level, the US Department of Treasury also regulates these businesses.19 The auditing and reporting requirements are as strict for money transfer companies as they are for banks in order to prevent money laundering, and since September 11, 2001, terrorist financing.

Some banks are trying to compete in this market, given that the overall amount remitted is significant, even if individual transactions are so small. Bank of America and Wells Fargo, for example, issue debit cards so that their customers can give them to relatives back home to withdraw funds regularly, normally through ATMs.20

Governments are also trying to harness these financial flows as well as reduce transaction costs, with Mexico perhaps the most advanced due to its close economic relationship with the United States, the world's largest remitting country. According to Manuel Orozco, six US banks have `signed up for the Federal Reserve's Mexico automated clearinghouse (ACH) system, through which money is sent to the Federal Reserve, then is transferred to the Central Bank of Mexico. The two central banks jointly set a foreign exchange rate cheaper than that charged by the traditional wire transfer services.'21

Where does the money go?

In terms of where the known flows go, experts reckon that Latin America receives the largest percentage, at 30 per cent (which is more than double all foreign aid to the region, including grants and loans from multilateral lending institutions 22), followed by South Asia (20 per cent), the Middle East and North Africa (18 per cent), East Asia and the Pacific (14 per cent), Europe and Central Asia (13 per cent), and Southern Africa23 (5 per cent). Within regions there is enormous inconsistency. India - the world's largest recipient of remittances - receives 73 per cent of the South Asian total; Mexico gets 34 per cent of the Latin American flow; and the Philippines 43 per cent of the East Asia and the Pacific total.24 Concerning funds remitted to Africa and their ranking at the bottom of recorded indices, the true figures are likely to be far higher than the data reveal because most remittances to Africa are unreported and a large percentage goes through informal channels because financial structures are weaker.25

What is the development potential?

Remittances have comprised the `second largest source of net financial flows to developing countries'26 over the last decade. Donors have thus begun to pay more attention to this phenomenon, not only because an improved understanding of these flows would greatly facilitate donor programming and needs assessments, but also because of the collective potential of remittances for investment and `for their contribution to Forex reserves and longer term capital in local financial systems'27. According to Orozco, `Approximately ten per cent of remittances received are saved or invested, thus providing an important source of credit for private sector institutions in the local economy and an incentive for development players, like micro finance and savings and credit institutions'.28

Several donors have in fact been experimenting in this area by dedicating funds to projects that support remittance systems or partner with collective remittance programs and microfinance institutions, in particular the Inter-American Development Bank, The United States Agency for International Development29, the International Fund for Agricultural Development of the United Nations, the Inter-American Foundation, GTZ, the World Bank and foundations such as the Ford Foundation and the Rockefeller Foundation.30

Perhaps the most successful examples of the collective potential of remittances are the Home Town Associations (HTA), which are small groups of Hispanic immigrants in the United States who come together to support projects back in their home towns. Often they team up with their home government to leverage these funds into bigger projects. In Mexico, for example, the government has a `3x1' program, in which such projects that support the local community are matched dollar for dollar by the federal, state, and local authorities.31 In addition to the HTAs, other groups of migrants have conducted fund-raising activities, often via the internet, to support projects back home through the collective use of remittances, although this only represents a small fraction of funds transmitted.

Other governments, such as the Indian32, Moroccan and Malian governments, have also launched initiatives to support their nationals abroad, and in turn, encourage more development-led investment projects back home.33 Host governments are also initiating projects. For example, Malians in France and Senegalese in Italy work with the French and Italian authorities to design appropriate projects in their home town.34 This `twinning' activity involves joint development, funding and implementation of projects with host governments, diaspora communities and local or national authorities in home states. Other creative programs have been launched, such as a health insurance scheme for Ghanaians at home supported by Ghanaians abroad.35

Yet even with these recent initiatives, there are still a number of gaps in understanding how remittances can be best used for development purposes, not only because most figures are estimates, but also because the strict regulatory requirements of many host states can create unwieldy and costly bureaucratic and accounting procedures (for example, European states, the United States and Canada all have different procedures). New policy incentives need to be developed to harmonize systems, while also lowering transaction costs for both the formal and informal transfers, with care given to methods of supporting local development without obstructing local initiatives. Finally, on the negative side, some remitters worry about `remittance dependency', which could undermine incentives for those receiving them at home to look for work.

Somalia and remittances: What do we know?

The remittance system in Somalia dates back to the 1970s and was developed as an alternative to the corruption and stringent government regulations found in the public sector. According to Dahabshiil documents, `At that time, the government set the exchange rates between the Somali Shilling and foreign currencies. There were also restrictions on the purchase of hard currency by traders from the state banks for imports. These restrictions led to the creation of an unofficial parallel market, whereby importers or their agents would collect money from migrant workers in Saudi Arabia and the Gulf countries, who wanted to send remittance to their families. Hence remittance became a major source of foreign currency for importers, and trade turned out to be the main vehicle of remittance.'36 In the 1980s, for example, it was estimated that repatriated money equaled two-thirds of urban income.37

Since the state collapsed in 1991 and all formal banking institutions disappeared, the money transfer services have become the only means of transferring hard currency into the country (all major exchanges are now made in dollars). Today a very small amount of cash physically travels with some Somalis and some internationals, but the vast majority moves electronically through money transfer services. Thus the case of Somalia does have some unique features from other cases around the world. Given that the country has been without a representative government for over a decade, distinctions between formal and informal are less relevant. Indeed, since that time, a vibrant Somali remittance sector has thrived and expanded to a large number of countries throughout the world. The success of these companies is based on the massive out-migration because of the civil war and subsequent humanitarian disasters, and because of the growth in communications technology, which have made transfers quicker and cheaper.

While the total number of Somalis in the diaspora is unknown (nor indeed are there exact figures for the population in Somalia), an estimated 750,000 Somalis who live in Europe, North America, the Gulf states, New Zealand and Australia send money to their families in Somalia, in neighboring states, as well as in refugee camps. For example, in Dadaab refugee camp in neighboring Kenya, an estimated 10 to 15 per cent of Somali refugees receive remittances.38 In addition, many Somalis living in neighboring states in East Africa also remit money into Somalia.

While data is incomplete, studies undertaken indicate that between 25 and 40 per cent of all families in Somalia receive remittances.39 A KPMG study estimated that total remittances used for household purposes reached $360 million annually, which equals 22.5 per cent of total household income. It also estimated that the gross remitted annually is between $750 million and $1 billion.40 This would include funds for business and other non-vital household expenses (such as qat). In times of crises in Somalia, as in other countries, remittances increase. Some experts attribute the high level of remittances for sustaining the Somali economy during the bans on import of Somali livestock imposed by Gulf states in 1998 and again in 2000 in response to Rift Valley Fever. The contributions by Somalis in the diaspora have thus largely been responsible for ensuring the livelihoods of Somalis over the last decade.

From the late 1990s, Somali money transfer companies even began to transfer funds on behalf of international aid agencies into Somalia, given that there is no other way in lieu of physically carrying cash into the country, which most aid agencies are reluctant to do. (The same also transpires in Afghanistan, with up to several hundred million US dollars transferred into the country by international development organizations.)

Somali money transfer services posit that they are not in fact informal hawala agencies, but instead are formal. As Dr Shire, a senior representative of the largest Somali money transfer service, Dahabshiil, explained, `If an organization specializes in remittance then it is likely to be formal. Also, the licensing and the registration; if an organization specializes and is registered or licensed to carry out that business that makes it formal. If it is incorporated also that makes it all the more formal, and if it keeps records that makes it all the more formal.'41 Indeed, Somali money transfer companies operate some services like regular banks, providing cheque cashing and deposit facilities, small loans, money transfer within Somalia, monthly statements, and other banking services. They also have developed a number of ways of ensuring accountability of their customers and employees, for their own purposes, which brought them into compliance with international financial regulations, particularly concerning `know your customer' and `know your processes' in money laundering and terrorist financing regulations.42 In many respects it could be argued that these money transfer houses `know their customers' better than formal banks as the service works entirely on trust, through clan and kinship arrangements.

In November 2001, the US government froze the assets and shut down US operations of Al- Barakat, formerly Somalia's largest money transfer company, because of alleged links with al-Qa'ida. Since then a number of Somali (and other) money transfer companies have been monitored and put under pressure to strengthen their accountability and transparency mechanisms. Most have made changes, some have been shut down by US officials, while discussion is on-going amongst the remaining money transfer companies as to overall improvements, although for obvious reasons, the Somali system is entirely run through selfregulation. Most of the money transfer companies have now joined to establish the Somali Financial Services Association, which is working in close cooperation with UNDP to assist with accountability and transparency measures.

While data on remittances going into Somalia is extremely difficult to obtain, more research has been conducted on flows into Somaliland. In Somaliland (and elsewhere in Somalia), remittances are received in the main by urban households. In Hargeisa, for example, there are more than 20 money transfer companies, and 50 internet companies.43 One study found that the average annual remittance received by households was $4,170 and that there were approximately 120,000 recipient households in Hargeisa, which has a population of approximately 450,000.44 While this study estimated that the majority of residents in Hargeisa are dependent on remittances for their livelihoods, the author notes that less than 5 per cent of rural households receive remittances. He also noted that women are increasingly becoming the main recipients as well as the main remitters.45

Chapter 3: Somalis Helping Themselves - Focus and Impact

This chapter examines how Somalis have adapted to the realities of state collapse, that is, how those who have remained in Somalia, the Somali diaspora, the business community, and clan and civil society structures have coped. The chapter concludes with a more focused analysis of how these same groupings have managed issues of health care.

The Somali Diaspora

The Somali diaspora is not homogenous. One should be cautious about making general statements and assumptions about the interests and motivations of people in the diaspora. Somalis are dispersed across the globe, and often dispersed within host countries. They are divided along clan, class and generational lines and by education and skills. Their experiences of forced migration and economic migration differ. Social bonds are stronger among some clan groups than others. They live in countries with different economic opportunities and asylum policies. Some Somalis are more interested in returning to Somalia than others. The largest source of Somali remittances is the United States, where employment and business opportunities are considered to be superior to other places. All of these factors have a bearing on relationships between Somalis in the diaspora and Somalia, as well as their aspirations for their immediate families, clans and country(s). These factors also influence the amount of financial resources that Somalis remit to Somalia and the forms of development that they support.

Opinions differ among Somalis as to the future of the diaspora. Some believe that many in the diaspora will return to Somalia once a government is formed and stability is reestablished. Many fear that the attachment of Somalis in the diaspora to Somalia will diminish over time, and subsequently assume that levels of remittances will decrease accordingly. Others will be forced or encouraged to return by changing asylum policies. Some Somalis posit that Somali migrants are no different from other migrant populations and that most will not return to Somalia. They argue that remittance flows to Somalia will not be sustained when Somalis see themselves first as US nationals, for example.

The diaspora and remittances are also vulnerable to changes in the economic environment in host countries and changes in asylum policies. An uncertain future is a weak basis for long term planning and raises questions over sustainability of diaspora engagement in Somalia's development. Some argue that the future of the diaspora is to uncertain to be able to provide a stable form of finance for development, and that the only durable form of long term support for social services will therefore be a taxation system.

The current trend among the diaspora would appear to be both of assimilation and transnationalism. There is a process of assimilation by Somalis in host countries and this is likely to increase over time. At the same time, there is evidence of Somalis establishing and deepening transnational linkages between Somalia and host and other countries.46 The long term relationship between the diaspora and Somalia will thus likely remain dynamic.

Forms of support have indeed changed over time. In the early 1990s warlords raised finance from the diaspora. This type of financing has dried up. Instead diaspora support has become more community and sub-clan focused, although the Somaliland diaspora still contributes to certain public goods, such as Hargeisa hospital and the Hargeisa orphanage. Diaspora interests also evolve, for example, today they focus more on support for political parties.

Forms of Diaspora Organization and Association

As noted, a common criticism of diaspora engagement in development in Somalia is that it is unplanned and uncoordinated. A key issue in generating diaspora support for health services would therefore be to develop an institutional and organizational framework for such engagement. Some argue that this can only be provided by a government. In the absence of government, however, diaspora engagement in Somalia has taken a number of different organizational forms:47

1. Nuclear family. The most common form of engagement and the one through which most remittances flow are in support of family livelihoods and specific crises.

2. Extended family networks. This is an extension of the above, often invoked in periods of crisis, such as a natural catastrophe.

3. National/sub-national citizenship. Many Somalis in the diaspora organize on the basis of their region of origin. This is particularly relevant to Somaliland and Puntland, but also significant for other regions like Hiran, Bay and Bakool. This form of organization can be seen in various regional websites. The web-based Somaliland Forum 48, for example, has been an important vehicle for influencing political developments in Somaliland and raising support for reconstruction. It demonstrates that the diaspora can, when circumstances are right, be organized on a regional basis. The collective response to the rehabilitation of Burao by Somalis from that town is another example and has similarities to the Home Town Associations in Mexico. This form of support may also come from individuals who are looking to leave a visible legacy in their region.

4. Associations: There are numerous examples of people in the diaspora organizing as associations and community organizations to support certain developments or to invest in projects. The types of projects that fall into this category includes those that support educational facilities. These associations can take the form of sub-clans associations, such as support for a particular school in a specific district, or cross-clan forms of collaboration, such as occurred with Mogadishu University or Hargeisa Group Hospital.

Another form of association is linked to the country of asylum. In Hargeisa, Somalis holding foreign passports have established associations for Canadian Somalilanders and British Somalilanders. Candlelight and Doses of Hope in Hargeisa, Horn Relief in Sanaag and the Somali Association of Health Care and Education Development from the central regions of Somalia were all started by the diaspora or with financial support from the diaspora. Many of these associations are increasingly making innovative use of new technologies, such as the internet, to raise funds and keep supporters informed.

5. Transnational partnerships. This form of organization is particularly relevant to businesses, such as the telecommunications companies, which are both transnational and trans-regional within Somalia. Somscan is another kind of transnational partnership with Somalis from different clans in different asylum countries pooling resources to build a new settlement outside Burao.49

The Diaspora and Development

The Somali diaspora have played a crucial and complex role in state collapse, the war and recent developments in Somalia. Their impact on current developments is apparent in several ways:

1. Livelihood support. Remittances to support extended family networks comprise at least half of the money sent by the diaspora through money transfer companies to Somalia. The major part of regular family remittances is used to meet consumption needs, including health and educational services. Remittances are also important in sustaining `social capital', such as through the financing of marriage and payment of dia.50 The role remittances play in meeting emergency survival needs is apparent in various disaster situations: the response to the floods of 1997, the embargo on livestock exports from Somalia, and currently the drought in Sool and Sanag. It is important to separate livelihood forms of remittances from financial transfers aimed to support particular development outcomes or business and trade.

2. Security. The diaspora impact on the security environment in various ways. They have supported peace talks, they may still help with the purchase of weapons for some families, and can be a destabilizing force when they are unhappy with the status quo.

3. Politics. Some of the political-military movements in Somalia have been started and funded by Somalis living outside Somalia. The SNM, for example, mostly depended on diaspora funding. During the war in the late 1980s the armed factions mobilized support from their clan members in the diaspora. The diaspora continue to play an important role in politics. They have contributed to peace talks, such as the one held in Arta, Djibouti in 2000, and Mbgathi, Kenya in 2004, through organizations such as Somali Peace Line, or to ending hostilities in Somaliland in 1996 through the Somaliland Peace Committee. They have become influential in the multi-party system adopted by Somaliland. Both Kulmiye and UCID political parties in Somaliland draw much support and ideas from the diaspora. UCID's leader is a returnee from Finland and promotes the creation of a welfare state. Kulmiye is said to have benefited from campaigning ideas brought in from abroad.

4. Capital investment. People in the diaspora have invested large sums of capital in certain business sectors, such as telecommunications, light industry and private infrastructure. to date, there has been some limited investment in public utilities and infrastructure, such as water supplies, schools and hospitals.

5. Housing. People in the diaspora have invested major amounts of capital in housing, particularly in Somaliland and Puntland. This has led to the rapid expansion of existing urban areas and the urbanization of rural areas, and has generated employment and secondary businesses. The social impact of housing on health should also not be underestimated.

6. Social services. The diaspora appear to have contributed more to education than any other sector, from primary education through to university education. The diaspora pay for school fees, teacher salaries, the construction of facilities, and the provision of materials and expertise. The diaspora have also supported health services, which will

7. Civil society and social welfare organizations. Some Somalis returning from abroad establish NGOs in-country. Some of these retain support from the diaspora. The diaspora is also helping to exploit new sources of capital outside Somalia, such as foundations and grant making bodies, both in western and Islamic countries.

8. Business. The diaspora invest in various businesses, from multi-million dollar business ventures, like the Coca Cola factory in Mogadishu (there are plans for a Pepsi Cola factory in Hargeisa or the Ambassador Hotel in Hargeisa, to petty trade, tea stalls and selling qat. The larger business ventures often involve some form of transnational partnership. In many regions, the `season of diaspora' (June-September) injects a significant amount of capital into the economy. The diaspora have been key innovators, bringing in new technologies like telecommunications, and the export of chilled meat. Some are also starting to experiment with animal ranching (reported around Hargeisa), which if successful may see new forms of animal husbandry as an alternative to pastoralism.

9. Skills and knowledge. There is a transfer of skills and knowledge from the diaspora, through returning professionals, particularly in business and new technologies, but also in social services, such as with doctors and teachers.

10. Religion. Imported Wahhabi-oriented religious practices appear to be replacing the traditional salahiya and gadariya sufi tariqa. This is apparent in the growth in mosques, educational establishments and religious charities. The change appears to be greater in areas that were traditionally salahiya (e.g. eastern Somaliland).

While the diaspora are contributing to many positive developments in Somalia, some Somalis and aid agencies are concerned that remittances are creating a new form of dependency and that promoting diaspora investment in social services will only exacerbate this. They argue that it would be better to encourage the use of the remittance money to generate employment opportunities through business development. This could build on what many families in the diaspora are doing to support income generation activities in Somalia, to ensure that their relatives have a regular income and to reduce their sole dependence on remittances.

Unplanned Development

While there is an appreciation that the diaspora do contribute to development in Somalia, it is largely unplanned in nature. This can lead to unnecessary duplication of effort and a waste of investments. For example, universities receive books that cannot be used, and hospitals receive inappropriate equipment or the wrong types of drugs. The interest (and sometimes pressur on the diaspora to support their community or area of origin can, for example, lead to a duplication of schools in an area that only requires one. In Somaliland such developments are sometimes not coordinated with the existing public system. In the South there is no government with which to coordinate such efforts, though in Mogadishu the Somali associations FPENS and SAFE provide some coordination and regulation.

Consistent with forms of international assistance, diaspora investments are vulnerable to local politics. In 1998/99, for example, the Burao diaspora was active in raising resources to rehabilitate Burao, channeled through the Mayor's office. This was disrupted when the Mayor was dismissed by President Egal, and the diaspora did not trust the new Mayor.

Hargeisa Municipality, for example, is promoting diaspora investment in Somaliland. In July, at a time when many diaspora visit Somaliland, the Mayor held a dinner for people from the diaspora, and attempted to persuade them to invest in light industry. The Municipality is also supporting diaspora investment by `fast tracking' the procedures they need to go through to purchase land, for example, and offering discounts on the cost of registration. The Mayor has undertaken tours to the United States, the United Kingdom and the Netherlands, at the invitation of the diaspora, in order to raise awareness of the democratic changes in Somaliland, and present a vision for the country and its needs. He has lobbied the government to reduce taxes imposed on the diaspora at the airport and the requirement for them to change money. The Municipality has a website for Hargeisa, which promotes the business environment in Somaliland.

One reason for the unplanned nature of diaspora investment in development is the lack of national goals, and as Somalis put it a `common cause'. Some argue that more effective, planned development can only be achieved with a government coordinating investment and setting priorities. Others suggest old development paradigms of government-to-government and government-to-NGO aid have all failed in Somalia. With a large overseas diaspora, Somalia has become a transnational society with a new type of economy, one that is largely generated from outside its borders. The importance of diaspora capital is clearly recognized, and while some express concerns about dependency, most accept and encourage continued investment.

Unequal Development

The developmental impact of the diaspora on Somalia is uneven. Certain groups have more access to diaspora support than others. This is related, in part, to historically established communities abroad, who could finance the migration of family members, but it is also related to an element of luck, depending on where a refugee, asylum seeker or economic migrant ends up. The largest amount of remittances come from the United States, Canada, the United Kingdom, Norway, Sweden and Denmark. Somalis who found refuge in those countries were able to develop better income streams for themselves and their families. While most remittances flow to urban centers, their impact may be greater in more marginalized areas. In eastern Somaliland, for example, which is marginalized from the economy and politics of Hargeisa, diaspora support is very important.

Somaliland and southern Somalia

The main difference between Somaliland and southern Somalia is the existence of a public health administration that maintains a role in the provision of health care. This administration is paid for by a combination of taxation and foreign aid. The Somaliland administration contributes 8 per cent of its annual budget of $20 million to social services. This is mainly consumed by salaries, but it has also contributed to the rehabilitation of health facilities. The ministry of health is also involved in the development of health policy and brings some regulation to the sector, such as over the import of drugs. The health administration in Puntland is less developed than in Somaliland and has a smaller revenue base to finance a public system.

Strategic Migration

Historically, migration has been one of several economic strategies of Somali families. It has been argued that some clans have actually created a diaspora as an economic strategy. For example, the Dulbahante are said to have exploited immigration loopholes to get to the United States in the late 1990s. This has resulted in increased remittance flows to Dulbahante areas in Sool and Sanag region. Despite, or because of their perceived marginalization from Hargeisa, this has stimulated reconstruction in urban centers like Las Anod. It has also enabled them to establish a degree of economic and political independence from the Hargeisa and Garowe administrations.

A common strategy by Somalis in the diaspora has been to obtain dual citizenship. Many Somalis returning to Somalia do so only after they have become citizens of other countries. Dual citizenship creates a form of transnational society.

The Differential Impact of Asylum Policies of Host Countries

Asylum policies of host countries can influence forms of investment for the diaspora. In Norway, the government welfare program involves assisting refugees to build and eventually buy their own houses in Norway. With this collateral, most Somalis who are in Norway are said to have been able to build houses in their area of origin. This contrasts with the more restrictive environment in the Netherlands (and in Canada), where the policy of dispersal and assimilation prevented Somali communities from becoming established. In the Netherlands, Somalis also face restrictions on access to higher education. It is reported that even those who excelled in secondary education tend to be directed to technical colleges. A bureaucratic business licensing environment means that Somalis also find it difficult to establish businesses.

For these reasons many have moved to the United Kingdom, even though they were receiving better welfare benefits and access to better quality services in the Netherlands. The United Kingdom is seen as having a more liberal business environment - `because the British government does not want people to be reliant on state welfare'.51 There are also reported to be better educational opportunities for Somalis. It will be important to be aware of changes in asylum policy, particularly in Europe, and how these may have and will affect migration patterns and remittances systems and flows to Somalia.

The Health Sector

Since the Somali state collapsed, and with it a national health system, international agencies (including Islamic charities), Somali health professionals and regional authorities have responded with a mixture of emergency health interventions and longer term programs to try and re-establish a semblance of a health system in Somalia. There is currently no such system. Instead international health agencies collaborate through the SACB and with Somali health professionals and regional authorities to formulate policy and address the health needs of Somalis. Today, there are 50-60 international organizations supporting health in Somalia, including Islamic charities.

Available evidence indicates that despite these efforts Somalia has some of the worst health problems of any country in the world (see table below). Life expectancy is 47 years and nearly one-quarter of all children die before the age of five. In fact this situation is little different from that pre-war. Indeed the collapse of the health system in Somalia began prior to the war. There is some evidence, however, that while health indicators show no improvement, access for some people to health facilities may have improved.

Health Indicators 52
Life expectancy at birth (years): 47 years
Under-five mortality (# of deaths per 1,000 live births): 224
Maternal mortality (# of deaths per 100,000 live births): 1,600
Access to health services: 28 per cent
Number of doctors (# per 100,000 persons): 0.4
Children 1-5 immunized against all childhood diseases: 27 per cent

As with other social sectors, state collapse has resulted in the decentralization, deregulation and privatization of health services. In 1997, evidence indicated that up to 75 per cent of people in some areas were obtaining their health services from the private sector.53

International health agencies, through the SACB, have sought to bring some regulation through common health policies and practices, though as will be discussed in the next chapter, more needs to be done. Some health care provision, such as vaccination, polio and emergency responses to cholera, remains centralized through international agencies. According to the SACB,54 the health sector is relatively better funded by international aid than other sectors, but still is under-resourced. In 1997, health agencies adopted a pragmatic policy to decentralize the management of the health sector. The policy recognizes that health is no longer free for all, and promotes community financing of public health services through costsharing. Regional Health Boards (RH
b) were formed to oversee the management of health services in each region. The rationale was that if people are paying for their health services, they should have some say in their management.

Key Problems in the Health Sector

Somali and non-Somali health professionals identify several key problems in the health sector:

1. There is a chronic lack of qualified health professionals. no new doctors have graduated in Somalia since 1988. Many have migrated overseas and those that remain work primarily in urban areas and in any case are in need of training or re-training. no new midwifes have been trained in Somalia for 15 years. With no newly qualified young people replacing them, the health system is facing a crisis. This requires a long tem investment in education and training. New nurse training facilities have been established in Mogadishu University, Bosas so and Hargeisa, and some new nurses will graduate soon. A few doctors have returned from the diaspora - for example, in Merka, Garowe, Hargeisa - but creative strategies are needed to attract more professionals to return, as well as to upgrade the skills of those in Somalia.

2. Governance of the system is poor. The management of health services is weak, from the level of individual facilities through to regional administrations. The record of RHBs has been mixed, dependent on the quality of management, the security environment and presence of an effective international agency. The RHB for Galbeed would currently appear to be one of the better ones.

3. There are limited resources to finance a health system. Public health services are subsidized by foreign aid. The administrations in Somaliland and Puntland do allocate some money to the health sector, but this amounts to less than 3 per cent of their budgets. With the exception of immunization and some primary health care services, which are internationally funded, most health provision carries some cost. The lack of public money for health means there is little incentive for health professionals to work in the public sector. In Somaliland, a doctor can expect to earn $30 per month from a government salary, compared to a minimum of $300 in the private sector.

Developments in the Health Sector

There are several developments in the health sector worth noting:

Private hospitals. Private pharmacies and private clinics have proliferated in Somalia since the state collapsed. The past three years have seen a growth in private `hospitals' throughout Somalia. These include Al Arafat in Mogadishu and Edna Aden Hospital and Al Shifa in Hargeisa. These fill a gap in referral services, as many hospitals closed in the 1990s. These new hospitals have been financed in different ways. Al Arafat in Mogadishu has received substantial financial support from private benefactors in the Gulf. Al Arafat, Benadir and Danile in Mogadishu have also received support from the diaspora. Dhuusa-mareeb Hospital in Galgaduud region was rehabilitated by the diaspora. Edna Aden Hospital has largely been financed through diaspora support. Galkayo hospital appears to be very dependent on the personal financing of one Somali doctor, as does the new Al Shifa hospital in Hargeisa.

There is very little information available about these privately-run facilities, and to date there has been only limited collaboration with international health agencies. These hospitals are generally better equipped than public hospitals and are assumed to be better run. As with other aspects of private development, however, there are several concerns: a lack of coordination and planning in terms of what facilities are needed, a lack of oversight and regulation, and restrictive access for the poor. In terms of the latter, all the hospitals do provide some free services for those identified as poor. Al Arafat, for example, provides a free service on Fridays.

While it is generally acknowledged that the current semi-private health system will continue for some time in Somalia, the system is not without problems. It is difficult to control, for example, the importation of uncertified drugs, uncertified antiretroviral drugs and antibiotics. There is also some resistance among administrations and some health professionals to private hospitals. In Garowe, for example, the proposal by the Amal remittance company to invest in Garowe hospital has not been accepted.

Cost sharing. There is a growing debate about the efficacy of cost sharing or cost recovery in the health sector. Introduced as part of the 1997 health reforms, it is widely practiced in Somalia. However, while it has led to an attitudinal change among the public about free services, it has not proven to be effective in sustaining services. It is now felt that the introduction of cost-recovery in Somalia may be limiting the utilization of services by the poorest.55 A Somali Red Crescent Society (SRSC) survey in a rural community in Somaliland indicated that 25 per cent of people have to borrow from relatives to afford health services, even those who might be receiving funds already from the diaspora. Cost-sharing also needs the close supervision of NGOs and others, which in itself is costly.

Regional Health Boards. The RHBs have had a mixed record in Somalia, including problems with the quality of management, local politics and security. In Somaliland the approach of decentralization was set back by the government's centralization of tax collection, which reduced the capacity of municipalities to raise taxes and to pay salaries.

The Galbeed (Hargeisa region) RHB, however, illustrates some positive aspects of the approach, which is ultimately dependent on commitment of personnel and a positive security environment. to date, its impact has been more apparent in the improvements in the management and financing of Hargeisa Group Hospital, where it is demonstrating the potential of combining public and private interests in health service provision, and in attracting support from the diaspora. Improvements in the quality of gynecological services means they are able to compete with more expensive services provided by Edna Aden's private hospital. They have yet to demonstrate an impact on regional public health care provision, however.

Another positive example comes from Haradere and El Dhere in Galgaduud and Mudug, where there are two small hospitals and a network of MCHs. Here the community has twice been mobilized to meet the costs of salaries and drugs during periods when there was no EU funding. It has also benefited from long term consistent capacity building from the Italian NGO, CISP.

Medical Associations. Another development has been the emergence of Medical Associations. The development of medical associations mirrors developments in other sectors of society, where professionals and skilled labor are becoming more organized, including in transport, the legal profession, and milk marketing. These may represent the evolution of an indigenous civil society.

These informal, voluntary associations of doctors currently exist in Mogadishu, Somaliland and Puntland. They have developed separately and differ in their activities, but appear to have a common purpose of protecting the interests of doctors,56 giving them a united voice, establishing some form of self-regulation and principles of best practice. In Somaliland doctors must be registered with the government Medical Council to be accredited. In Puntland and Mogadishu the medical associations provide a similar function; in Puntland names of accredited doctors have been put on a website. The Medical Association of Mogadishu is reported to receive some support from benefactors in the Gulf and is more like an implementing NGO than an association with regulatory and oversight functions. It runs two to three hospitals in Mogadishu and focuses on provision of medical care with some training.

The Medical Associations could become a focus for promoting public health and a possible entry point through which to channel diaspora support, particularly human resources. Their advantage is they have a broad level of outreach compared to NGOs.

The Diaspora and the Health Sector

Diaspora support for health appears to take two main forms. First, family remittances meet needs for common and emergency medical treatment, including evacuation to other countries. Second, groups in the diaspora mobilize funds in support of health facilities, primarily hospitals. These are often in response to particular appeals from people in-country and for specific institutions that they happen to be interested in. Support comes in the form of equipment, medicines and some health professionals, but rarely cash.

Much of the support is in the form of one-off contributions and its usefulness varies. When it includes inappropriate equipment or the wrong drugs, it can actually prove to be a health risk. Such situations could be minimized with better needs identification and organization, and closer communication between health professionals in diaspora groups. In other words, funding in and of itself does not automatically improve the quality of service. Hargeisa hospital has been able to attract funding for rehabilitation, but was unable to respond adequately to the last meningitis outbreak because they did not have the appropriate technical expertise.

The Italian NGO, COOPI, which works with several hospitals, acknowledges the contribution of the diaspora, but points out that the support is not well organized. One of the problems is the people making the request - health professionals, administrations, and clan elders - are often overly focused on their own specific requirements, and ignore wider needs. The diaspora needs to be sensitized to these issues, and have greater access to health professionals who could guide the use of diaspora support. That said, another form of diaspora engagement has been the return of health professionals, but they in turn often face problems reintegrating. In many instances, they are poorly utilized by local authorities and administrations, and end up being employed by international agencies.

The Business Community and the Health Sector

In the absence of government, the private sector has taken on certain roles in health provision - the supply of drugs through pharmacies, and the provision of medical care, from the diagnosis and treatment of common aliments, to midwifery and complicated surgery. The focus of private health care is almost wholly curative care, with only limited involvement in primary health care and no involvement in preventative health care or sanitation.

There is also an emerging trend of corporate social responsibility among some businesses. All companies pay zakat, but some of the larger ones also appear to be contributing to community reconstruction and development projects. For example, Telesom in Somaliland spends some $18,000 a year on projects for the community. This has included contributions to building the Borama-Hargeisa road, a bridge in Burao, a wall around Hargeisa airport, school buildings, support to the universities of Hargeisa and Borama, and rehabilitation of the orthopedic ward at Hargeisa Hospital. They see it as part of their social responsibility and as good for public relations. Medina hospital in Mogadishu was re-opened with contributions from the business community, mobilized by a women's organization (HINNA). The telecommunications company in Mogadishu - Nation Link - contribute $15,000 to Mogadishu University. In July 2004, business people in Mogadishu donated $50,000 to the peace process.

In addition to its bottling activities, the Somali-run United Bottling Company and Coca Cola in Mogadishu have announced the establishment of a corporate social responsibility program and foundation to support education, water, sanitation and social development. The Coca-Cola Africa Foundation (CCAF) has contributed $50,000 to the foundation for primary education and health community projects. Coke and UBC are also working with UN agencies to set up a further project to return 50,000 children and teens to school. Somali NGOs are also raising funds from the business community.

The money transfer companies also provide charitable support. For most, this takes the form of zakat which is disbursed in different ways. Some contribute to projects by exempting project money from transfer charges. Dahabshiil has plans to establish a charitable foundation, which they say will focus on education, health and the environment. One idea being considered by Dahabshiil involves a supplementary 1 per cent charge to their 4 per cent service charge. This voluntary 1 per cent donation would be put into a foundation for development, which the company estimates could raise $300,000 per year.

Health Financing

The idea that the diaspora could support the financing of a health system, or even individual health structures, requires an improved understanding of the cost of health financing in Somalia. Currently, neither international health agencies nor Somali authorities have any indication of what it might cost to finance a minimal health system in Somalia. There has only been one study on health financing, which looked at cost sharing. Most health facilities are run without budgets. It is therefore not clear whether, for example, the diaspora remittances at the current level could finance 1 per cent or 100 per cent of a health system in Somalia. It is generally accepted that no public health system, anywhere, is self-sustaining and there will always be a need for some government support. Certainly primary health care and preventative health care require public financing, which can probably only be met by governments or international agencies.

In Somaliland, efforts have been made to increase public expenditure on health. The government has committed $50,000 to Hargeisa Group Hospital. Parliament also approved an increase on the tax on cigarettes and qat to increase the budget for health. There is potential for increased and more systematic engagement in all of these areas. Somalis are finding new ways to engage the diaspora in developments in Somalia, such as through the internet. More diaspora members are exploiting other resources available in the host countries, such as foundations, and grants for projects. Donors and aid agencies could be more creative and strategic in facilitating the diaspora's role in development beyond social service provision. There might be a role in development agencies for `diaspora advisors' to explore ways to sustain and deepen diaspora engagement. This might, for example, involve advising a new government or regional administrations on strategies to engage the diaspora.

Chapter 4: International Efforts to Provide Health Care in Somalia

In Somalia, there are two categories of international assistance. One is the western institutional approach reflected in the Somalia Aid Coordination Body (SACB), and the other is Islamic charitable assistance that operates outside the SACB framework. The former reflects the procedures and structures of all inter-governmental organizations (IGOs), all OECD donors, and the majority of international non-governmental organizations (INGOs). The latter is paradoxically more blatant and more subtle. It is more blatant, for incidents of charitable giving can have clear and overt political objectives; and more subtle in that a considerable portion of Islamic assistance is provided in ways that blend with and support local customs and institutions, and reflect more of a culture of empathy than sympathy in dealings with recipients. This chapter discusses both types of assistance.

I Western institutional perspectives

In Somalia, conventional public health services are predominantly provided by the international community, principally UN agencies and international NGOs. The services that are solely dependent on international actors are mainly immunization and vaccination programs, and public health education.57 The international community also plays a predominant role in the provision of assistance when it comes to tuberculosis (TB), HIV/AIDS, nutrition and malaria treatment.

At the same time, a growing number of indigenous facilities are assuming particular aspects of public health provision, and are supported through Somali-run institutions and authorities. In the broadest interpretation of `public health', there are several noteworthy water and public sanitation services provided through local Somali and Somaliland authorities, which combine international technical support with local income generating schemes.58 There are several Somali hospitals that provide assistance to individuals with chronic illnesses and disease, for example. And, as also discussed in the previous chapter, a number of private clinics have emerged over the past three years in many parts of Somalia - including areas that are not always accessible to international experts.

In considering this uneven but clearly discernible trend of Somali-driven health care initiatives, it is worth reflecting on the extent to which such Somali initiatives are fostered and supported by the international community. And in that regard the answer is mixed. The term, `verticalism', has been used by one analyst to describe the ways that the inter-governmental and mainly western non-governmental organizations deal with health care in Somalia.59 In other words, despite the SACB's health coordination committee and the SACB Health Strategic Framework, there is little implemented that reflects a coherent or coordinated approach, as described in Chapter 6 `recommendations' section, for fostering an indigenous Somali health care capacity.

There are, however, worthwhile initiatives that directly and indirectly enhance a Somali health care capacity, though they are not part of a comprehensive strategy, either in conception and design or in implementation. Nevertheless, the activities noted below could have potential impact on a sustainable health care system, since directly or indirectly each relates to the indigenous capacities required to develop such a system. Even here, however, despite determined efforts by a variety of organizations, the majority of these initiatives are not anchored in any concept of a longer-term health care future, and -- as presently construed and operated -- could not be sustained in the future without continued international backing.

Direct international support

Institution building. Community Health Committees (CH
c) have been actively promoted by IGOs and INGOs alike, combining international training and initial funding with local community support to ensure a modicum of sustainability. The success of the CHC program has, however, been mixed. Though the numbers of CHCs have increased, their usage is inconsistent. On occasion they clash with regional Ministries of Health, and seem most effective when linked to other functional groupings such as `parent-teacher' groups. Similarly, international efforts have been made to support Ministries of Health, for example, in Puntland, Mogadishu, Bay and Bakool, and in Somaliland. However, all to often these ministries are caught up in the politics of their respective areas, and lack the authority, the structure or resources to act as effective health agents or promoters.

Health boards at regional and local levels, noted in the previous chapter, also receive the support of IGOs and INGOs, and some have expressed admiration for the ways that such boards have proven relatively adept at raising funds for medical facilities as well as effective advocates in terms of public health issues and medical professionalism. According to a recent survey for the EC, these boards have resulted in an improved `understanding of issues related to health care, its management and financing.'60

The international community also supports hospitals, some of which have training capacities.61 Examples can be found throughout Somalia, from Merka and Mogadishu to Hargeisa and Boroma. It is interesting to note that representatives of international organizations have referred to a range of such hospitals, yet there appears to be no consolidated hospital list. Again in Hargeisa, another example of a medical institution supported by the international community is a nursing school which, among other things, is intended to be a `training for trainers' center.

Capacity building. Capacity building in the context of this analysis involves a spectrum of activities, ranging from formal training and education to involvement in various one-off programs. The World Bank, for example, in recognizing the `acute shortage of skilled human resources' in Somalia, works with local partners and through joint assessment missions to identify centers that could be strengthened to provide health and livestock training.62 The Bank hopes that a suitable location can be found for a training center for the health sector, which would offer refresher, short-term and normal training courses for health professionals. At the same time, specific programs, such as for HIV/AIDS, have a range of training components which strengthen indigenous capacities, both in terms of medical and administrative abilities. The use of national consultants to establish HIV/AIDS training units, fellowships for training nurses and the training of epidemiologists within the HIV/AIDS program are indicative of the type of support that create additional health-related capacities in country.

Health codes and standards. The SACB has expended considerable energy to establish medical and health standards that guide its own membership. That these purportedly are not consistently followed by organizations within the international community reflects the challenge faced by those who attempt to promote similar guidelines within Somali healthrelated organizations. In any event, the international community, including the Somali Red Crescent Society, UNICEF, WHO, the European Union and others, have been involved in supporting a handful of Somali-based medical associations and regional and local health boards, and one of the important functions of these bodies is to promote health standards as well as to screen those who purport to be qualified medical professionals. International agencies have also attempted to establish medical service and health care guidelines for local authorities, including ministries of health.

Indirect international support

Demographic information and data collection. There is no doubt that lack of demographic data inhibits the development of a sustainable health service. A growing number of initiatives have, however, demonstrated that data - though not medical data, per se -- can be collected and that data collection expertise has been developed within Somalia. These initiatives primarily gather socio-economic data, enhance the data collection and analysis capabilities of Somalis involved, and provide a foundation for a future data collection system.63 From the health perspective, relatively sophisticated data collection efforts have been made regarding HIV/AIDS and TB. The Health Information System, initially proposed by WHO and taken over by UNICEF, was intended to establish a data set based on international donor needs, geared towards established international programs. to date, this particular initiative has reportedly been disappointing, though according to a recent analysis, nascent data systems are emerging in the Hargeisa Ministry of Health and a few hospitals such as the Garrowe Community Hospital.64

Remittance facilitation. In the Somali context, the importance of remittances as essential means for supporting livelihoods and various aspects of development have been given increasing prominence. Since 2002, significant efforts have been made by UNDP to accommodate the concerns of host governments about Somali money transfer companies and the use of remittances by Somalis for domestic investments as well as for livelihood support.

As has been noted in examples given in the preceding chapter, Somali-initiated collective remittances and those intended for families are increasingly being used for health care services, of a public as well as private nature. Hence, any initiative that can meet host governments' demands for transparency and enable the flow of monetary transfers to continue could prove to be an important factor at this stage in fueling a more systematic approach to health care.

Attention given to remittances has also opened doors for UNDP and the World Bank to consider the potential for alternative banking structures, e.g., correspondent banks, which in turn could facilitate micro-financing and possibly micro-insurance initiatives (discussed in the next chapter).

Public employee support schemes. The EU and a number of IGOs and NGOs have paid considerable attention to augmenting the professional standards of public sector employees. These sorts of initiatives include recommendations on approaches to public sector salaries as well as training programs.

Returnee programs. A variety of programs, such as UNDP's QUESTS initiative, are designed to encourage expatriate Somali professionals living abroad to use their skills to serve the Somali community back home. Health, education and agriculture are regarded as priority sectors. This program has not yet started - its success may depend on how these programs are publicized to the Somali diaspora, and also the extent to which they will allow those with essential professional qualifications to remain in Somalia for only portions of any particular year, with the right to go back to their host countries.

The range of direct and indirect support discussed here does not do justice to the overall efforts of the international community to provide for the health needs of the Somali people.65 Nevertheless, it does suggest areas where the international community has had some potential impact on promoting and fostering a Somali health care capacity. That said, representatives from a selection of INGOs and IGOs also suggested that these initiatives have been undertaken in a fairly ad hoc manner and in relative isolation, with little sense of how a more indigenously driven health care system could be developed. In that regard, four conclusions from international efforts to date need to be mentioned here:

1. Strategic policy gaps. Coherent and strategic approaches to fostering and promoting an indigenous health care system in Somalia still do not exist. Despite the many virtues of the SACB's health sector committee and its health strategy framework, there is no strategy that: i) looks to a longer-term, functional future towards which Somalis could aspire; ii) links the day-to-day activities of Somalis as discussed in the preceding chapter, with those of the international community, iii) relates the flows of collective remittances and the health interventions of the diaspora, e.g., purchase of equipment, to international objectives and activities, and iv) marries indigenous approaches to health care with international interventions.

2. Inadequate interaction with Somali culture and structures. Through the considerable efforts of a variety of INGOs and IGOs, many functional Somali-based institutions have been developed, e.g., MCHs, CHCs. That said, there is little evidence that a concerted effort has been made to assess the health needs and approaches that Somalis would want. Thus the conventional western-oriented system continues to work in ways that do not support comprehensive strategies for local ownership and sustainability. In parallel is an emerging Somali approach - random and at this stage unsystematic - that nevertheless reflects an active Somali commitment based on Somali resources, traditions and cultural assumptions and uneven degrees of western expertise. The former - paradoxically concerned about perpetuating a Somali `dependency syndrome' - does little to interact in ways that will support and sustain the self-help dynamism of the latter.

3. Lack of coherence. There are various aspects of the SACB's health sector that could be better coordinated, both within the SACB as well as between the SACB and other health providers in Somalia (e.g., Islamic charities and private hospitals). A recent survey noted an array of institutional overlaps and gaps, which could have been prevented had there been greater attention paid to coordination.66 This lack of coherence also reflects the fact that - health strategy framework or not - there really is no long term perspective or vision about Somali health care. Many in the world of IGOs, INGOs and donor governments explain this lack of vision as the inevitable result of no formal Somali government and government structures with which to dialogue. The reality, however, is that there would appear to be an emerging Somali approach that could offer the basis of a longer-term, more coherent strategic vision.

4. Lack of linkages. As suggested on several occasions throughout this section, there are clear gaps between health initiatives undertaken by Somalis in-country, supported by the diaspora, and the efforts of the international community. This calls for a new policy and strategic perspective in promoting and fostering health in Somalia. Yet, there is an equally important nexus that needs to be developed, namely, that between western assistance organizations and those of the Islamic world. to that extent, a much greater understanding and appreciation of the work of the latter is needed if it is to support a truly strategic approach to develop sustainable health systems in Somalia. It is with this in mind that special attention should be given to Islamic charities in Somalia.

II Islamic Charitable Assistance 67

Islamic assistance in Somalia is not a new phenomenon, but international efforts to understand its impact and scope are only at a preliminary stage. Islamic NGOs generally express willingness to coordinate with SACB bodies, but rarely do so in practice, and few needs assessments undertaken by international organizations within the SACB framework take into account the work of Islamic charities.68 In addition, Arab states that are involved in Somalia also rarely inform the SACB of their activities, and many of them fund the Islamic charities.69 Similarly, the charities themselves are circumspect about their financing, though many admit to receiving assistance from Arab states, which is usually combined with the fees charged to cover operating expenses.

A large number of Islamic charities operate in Somalia, though the exact number is not known. They provide health care, education, vocational training, orphanages, and improve access to and safety of water supplies.70 Most of these charities work in a number of sectors, few specialize in one service. In some respects they operate in a similar fashion to western organizations. Interestingly, and also similar to western organizations, they do not work with the Somali business community. According to LeSage, `None of the Islamic charities in Mogadishu noted any significant contacts with the local business community. This is surprising given the combination of the burgeoning coffers of some Somali businessmen and the Islamic injunction to perform zakat.While some Islamic charities expressed regret that their approaches to the local business community had been rebuffed, the majority responded that they were happy to steer clear of the `money lords' they felt to be `corrupt' and `self-interested'.

Yet in other respects, the work of Islamic NGOs appears to be more closely aligned with Somali needs, not only because of a common religious and often cultural heritage, but also because they appear to be less burdened with the security rules of international organizations. These often interrupt long-term stays in Somalia and do not allow internationals to work in certain places deemed insecure. This greater field presence of the Islamic charities gives them a better understanding of the evolving situation on the ground. For these reasons, it has been argued that they are more successful than western charities in capacity building and in developing sustainable social services. Often only an initial injection of funds is all that is needed as local counterparts successfully develop their own funding strategies to maintain operations.

Beyond the points noted above, the working practice of Islamic charities also differs from international NGOs in several significant ways. For example, charity employees actively seek out unemployed Somali professionals in Somalia and convince them to re-engage in their profession, particularly if it is a profession that is in need in Somalia (such as education or health care). They agree that the charity will provide logistical support (e.g., office supplies or rehabilitation of a school building or a health clinic), and a percentage of the salary for an agreed period of time, with the assumption that fees will eventually replace their contribution. As that particular enterprise becomes more self-sufficient, the charity slowly withdraws its support, though if it seen to be successful, the charity may expand activity.

The process described above takes place often over a sustained period of time, which western organizations do not always have because of budgetary and administrative constraints. The advantage here being that there is normally buy-in at many levels due to the lengthy discussions that occur throughout. Islamic charities appear to be less encumbered with the types of administrative procedures that are demanded of most western organizations in the development and humanitarian world. In addition, Islamic charities require local communities to be responsible for security, and if this and other agreed conditions are not met throughout the duration of the project, the charity will withdraw completely, something that western aid organizations are more reluctant to do. SACB organizations typically withdraw for temporary periods of time, and then often return in without necessarily having secured the substantive commitment that was requested. Some Islamic charities introduce small user fees for services provided, such as teaching, and then gradually increase the amount over time, and that process thus far has met with less resistance by Somalis in Somalia.

Several more radical Islamic charities also operate in Somalia, and provide basic health care in a number of areas, yet it is extremely difficult to obtain information about their activities. Those that are known in the area of health care include Rabidat, Munazzama al Da'wa al Islamiyya, a Sudanese-based international charity, which runs two small health care facilities in Mogadishu and Afgoye. Da'wa participates in some of the international coordination meetings and works with several UN agencies.

Thus while many members of the counter-terrorist coalition have become overly concerned with the potential negative aspects of some Islamic charities in Somalia, it appears that there are a number of positive factors that could be duplicated by SACB organizations, though issues of security will be more difficult to overcome. Somalis appear to regard Islamic charities as more successful in terms of contributing to long-term development in Somalia because of their active recruitment of unemployed Somalis in Somalia, their open-ended dialogue with few time constraints, their strict adherence to initial agreements of complete withdrawal if security is not maintained, their continuous field presence, their obvious cultural and religious affinities, as well as funding processes that promote sustainability.

Chapter 5: Somalis Look to the Future

Exploring the study's proposition

We Somalis listen to new ideas, particularly when there are incentives involved and we are good mimics, so if something works well in one place and it has a financial reward, you will see it spread to other areas very rapidly. (Somali participant in diaspora meeting, 18 August 2004, Copenhagen)

Somalia is the Wild West for businesses.anything is possible.But there is no need to accelerate things, by pushing new ideas [like health insurance]. If it is not locally owned it will not succeed. (Somali interviewed in Mogadishu, 3 August 2004)

The quotes above have particular significance for this study in at least four respects. First, the majority of Somalis interviewed did not come with any fixed views about ways to enhance medical services in Somalia. For those interviewed both in Somalia and in host countries, the issue of enhanced health services in Somalia began with an array of piecemeal suggestions or complaints, but initially there were few relatively holistic or creative ideas about responding to Somali health needs. That said, few non-health specialists from developed states would be able to elaborate such ideas either. The researchers were interested in whether Somali professionals, and health care professionals in particular, had considered options for the macro-provision of health care. In addition, the researchers also wanted to know if there would be interest and buy-in for several rather creative options, which potentially could be adopted with or without a central authority.

to initiate discussion, the researchers suggested possible approaches and ideas. These approaches and ideas arose from discussions with health, poverty and development economists and other experts focusing on remittances and development. This `seeding' approach succeeded in unleashing an array of creative proposals that reflected the particularities of the Somali case, and these are described below.

Second, the majority of Somalis who were interviewed appeared to acknowledge the importance of a privatized system based on incentives, but also saw a potential role for charitable giving. Third, all Somalis interviewed were extremely keen on the study itself. There was no instance where researchers confronted `doubters' or incredulity about the study by the end of interview sessions. to that extent, the purported interest that Somalis might have in new ideas seemed to have been confirmed, and particularly interest in ideas that would be Somali-driven. Fourth, as will become evident in this section, there was little overall agreement about the way forward. As should be expected from exploratory talks, no single stream of ideas or consensus emerged.

This chapter discusses options for sustainable health care in Somalia in six parts:

1) health care services in Somalia; 2) health care infrastructure; 3) security; 4) the establishment of sustainable health services; 5) payment systems; and 6) quality control.

1. Health care services in Somalia

Issues concerned with the provision of public health services, such as sanitation, vaccination campaigns, and public health advocacy and education, were raised by Somalis during interview sessions. Their focus, however, was principally on curative health and medical care, particularly for elderly relatives. From the diaspora, anecdotes abounded about the cost of sending relatives to hospitals in the Gulf, and the lack of understanding about preventative measures, even in terms of the need to wash hands (particularly when water is not always available). Some referred to the need for facilities to treat victims of violence, others mentioned mother-child health care requirements, and among the diaspora a good proportion discussed the medical services that they would require to return permanently or even for prolonged visits.

The medical needs of rural communities was an issue that had to be prompted by interviewers. This could have reflected the fact that Somalis interviewed were principally from urban areas. Nevertheless, many had extended family members in rural areas, and thus when the discussion turned to other forms of assistance provided by the diaspora in sectors such as education, it was interesting to note that many spoke `regionally,' e.g., in the context of support for schools in the Juba Valley in the South or in Awdal and Galbeed in the north-west. There were also occasional references to the potential for hospitals or health clinics emerging in small towns, such as the case of Afmadow noted in Chapter 3, well away from larger urban conurbations. On the whole, however, medical care was perceived to be an urban issue or at least understood better by urban dwellers, for which those in need would have to travel from rural areas into established urban areas.

Of an estimated 300 individuals interviewed for this study, there were only a handful, mainly with medical experience in Somalia, who mentioned `mobile clinics' as a way to provide health services to pastoralists or rural communities. In this context, there was little reference ever made to the work of the international community in providing health care through primary health care or MCH centers. Conversely, when issues of access to services by the poor arose, there was an assumption that the poor, as noted in section 5 below, would be covered because of clan affiliation and for reasons of religious obligation, such as through zakat, as well as through international and local organizations.

Only on one occasion did respondents discuss the study in terms of a national health care system. In that instance a politician from Puntland emphasized that when there is a national government, the role of that government would be to regulate a private health care system and not to operate a public health care system as in the days of Siad Barre. For the most part, the Somali vision of medical services in the future was more locally-based, a notion stemming from current realities (and the lack of a central authority). It also reflected Somali experience that localized, clan and kinship-based systems have proven to be more reliable than nationalbased ones. Not even the supporters of a separate Somaliland spoke in terms of a `state-wide' system, but rather pointed to the needs of Boroma, Berbera, Burao or Hargeisa, for example. Medical services in the country were focused more on urban areas, such as Kismayo, Merka, or Mogadishu, though the Mai community from the south-west Bakool region took a more regional perspective. Health care systems, themselves, were seen in terms of hospitals and clinics, essentially private, but with regulatory authorities that were based on clan elders and Somali professionals.

2. Health care infrastructure

There are no studies that give a complete picture of Somalia's health care infrastructure. As was noted in a recent analysis of possible capacity building for health interventions, the uncertain access that investigators have to various parts of Somalia make an accurate assessment of Somalia's health care system very difficult, while no Somali researcher has documented this either.72 From the Somali perspective, however, there appears to be three recurrent issues that emerge when discussing health care infrastructure, now and in the future: a) the quality of professional medical staff; b) the quality of medicines; and c) the types and standard of equipment.

There is no doubt that Somalis are concerned about the lack of sufficient and adequate local health care facilities. Yet, the most consistent concern expressed about the present health care infrastructure was the lack of qualified medical practitioners - nurses as well as doctors. Most Somalis interviewed for this study maintained that there were probably sufficient doctors in Somalia to meet the needs of the population in theory. The reality, however, was that the standards and qualifications of many who called themselves `doctors' were seen as suspect.

There was a recognized need to ensure the medical qualifications of those who purported to be doctors, and equally as important was the related need to establish training facilities that would ensure adequate medical standards for those wishing to become doctors and nurses, or those wishing to maintain their skills over the years through re-training. While many in the diaspora already paid for schools and universities and also for medical equipment and clinics, the training of medical workers was seen as an area where international organizations, NGOs as well as UN agencies could help.

Related to general medical infrastructure was the persistent concern about the poor and unpredictable quality of medicines available throughout most of the country. `Imitation medicines' from South Asia were harshly condemned as were the out-of-date medicines allegedly being sold in most market places. Some respondents assumed that more efficient medical services, including better doctors, could resolve this problem. On the other hand, one also accepted that medicines found in the market place were often the inevitable solution for those who could not afford doctors, and accepted the advice of the street seller. The majority of Somalis spoke of the need for regulation of doctors and pharmacies, and this will be discussed in the final section of this chapter.

A third issue that frequently surfaced during group discussions was the inadequate level of medical equipment. In that regard, one of the Somali diaspora's most consistent contributions at present to health care systems in Somalia is equipment. Examples were mentioned of Somalis in different countries, including the United States and Denmark, pooling resources to provide such medical essentials as X-ray equipment to their local community health facilities, although in several instances the equipment was subsequently stolen. The view of the Somali Doctors Association in the United Kingdom was that if equipment and salaries could be made available, the majority of doctors within the association would probably return to Somalia to practice.

3. Security

There is no doubt that medical facilities, such as the COSV-run hospital in Merka, have been periodic targets of clan and sub-clan rivalries over the past 13 years. They are potential sources of assets and also symbols of power and control. In those few instances when mobile clinics were discussed, the issue of security soon followed suit. They were regarded as particularly vulnerable. Probably far more dangerous from a security perspective, though, are threats to medical staff made by the distraught relatives of the sick and infirm. This certainly is the case when it comes to dealings with foreign staff, and part of the explanation for this potential danger is the lack of clan intermediaries between those who provide medical services and the relatives of those who receive them.

The importance of the clan intermediary or, more broadly speaking, clan structures as a means of providing security, was recognized by the majority of Somalis involved in the study. Clans, as will be discussed in section 6 below, might have other functions in terms of health care structures, but their role in the context of security was described principally along three lines: a) security of property and health infrastructures; b) security for medical staff; and c) security of access.

Clan intervention to ensure security for medical facilities involved a variety of complex tradeoffs. two important components of such trade-offs were the inevitable quest for employment and the provision of care. For the former, `the corrupting factor' of clan expectations that hospitals and clinics would provide employment for clan members, was regarded as unavoidable. Similarly, it was also assumed that there would be clan expectations that clan health needs would be given due attention. Security, itself, could not always be assured, even if such trade-offs were made, but at least in the absence of any conventional forms of security, clans could provide a modicum of stability.

Discussions about security often led to remarks about the ways that the Somali business community transcends clan issues, and that if the business community became involved in the field of health care, it probably would not have to deal with the same level of potential insecurity. In other sectors, this appears to be the case, though it is difficult to determine whether or not the human dimensions of health care would allow for the same sort of payoffs that enables the business community to circumvent clan rivalries and constraints.

One aspect of the human dimension of health care concerns the relationship between medical staff and the relatives of patients. Here, through the clan involvement in regulating dia, Somalis felt that adequate levels of security could be provided, particularly to Somali doctors and nurses who came from different clans or sub-clans within the same clan. Clan interventions and trade-offs would also help to facilitate access to Somali medical staff who otherwise would be unwilling to go into areas where `war-lords' and rival factions might make access difficult.

The security picture which Somali respondents painted was mixed and often contradictory. Nevertheless, there was a definite impression that the Somalis with whom the researchers spoke were far less concerned with security hazards, felt that that Somali health providers could rely on so-called `the Somali way of doing things', and in any event could go to areas where foreign staff normally could not.73

4. The establishment of sustainable health services

All modern health systems are dependent on a combination of charity, private practice, and some form of local and central government facilities, and regulation. When it comes to funding health services in Somalia, charity and private practice are available. to some extent, in the absence of central government authorities, a modicum of systemization and regulation could emerge in the foreseeable future by bringing together the array of existing Somali institutions involved in health care (e.g., CHCs, existing local authorities, regional hospital boards, ministries of health) into a broad functional framework. This initiative could be assisted and supported by the SACB, assuming that it, too, could exhibit greater singlemindedness and vision.

This sort of broad specter did not figure into the thoughts of those Somalis who were interviewed for the study. Their focus, reflecting in part their experiences in western countries as well as in Somalia, focused principally upon funding and payment mechanisms. In sum, their suggestions can be divided into four options, that is through schemes based on: a) charitable investment; b) cooperatives; c) capital investment; d) a combined scheme based on share options in an insurance scheme.

Each of these groupings depends on the continued flow of remittances, certainly in the short to medium term - and on the continued inter-action between the Somali diaspora and their home communities, beyond sending funds, for example, through the flow of ideas, support, expertise, and advocacy.

a) Charitable investment. Somali respondents overseas initially assumed that this study was designed to divert remittances away from their present uses into specific health care projects. When informed that this was not the case, most initiated discussions about ways that the diaspora could increase contributions for health care services. Often it was discussed as an extension of many of the activities that they already perform in the health as well as education sectors. They spoke in terms of pooling resources and raising funds for a specific cause, place, clinic or of ways to dedicate their zakat contribution to the health care of a family member or someone in dire need. In other words, the diaspora who were interviewed did not hesitate to talk about health care systems founded on their own charitable donations.

Most discussed such charity in terms of contributing to hospitals, buying equipment and even paying for doctors' salaries. Yet, at the same time, when talking about the sustainability of remittance-based charity, there was a significant portion of respondents who saw themselves as `the last generation' of Somalis that would follow that tradition, or who accepted that there were times when they could no longer sustain the burden of giving.74 That being said, the `export' of a family member to work abroad will remain a coping mechanism as long as there is a need at home. Charity was thus seen as an option, but not one that would or could provide a comprehensive system. Instead, ideally, it could be used to fill the gaps.

b) Cooperatives. Within the context of a clan structure, the concept of a cooperative, or shared ownership of a structure, is a relatively familiar idea to most Somalis, with the notion of `qaran' the most obvious example (the pooling of one clan's communal resources to be used to pay off another clan in the event of a dispute). The Amal Remittance Bank is also a `share-ownership' company, with all employees and agents part owners of the company.75 Thus the idea of a `health care cooperative' was of interest, even if the concept remained vague, and was generally defined in terms of a clan context.

c) Capital investment schemes. There was almost universal belief that the business community/private sector was the basis upon which a health care system in Somalia would have to be built. Somalis would trust such a system, and they would see the direct result or impact of their investment and fees. As noted earlier in this report, the diaspora has invested large sums of money in various business sectors - even in public utilities and infrastructure, including water supplies, schools and hospitals.

Reactions to capital investment were positive and negative. In the first place, as noted earlier, the business community was regarded as generally able to surmount security problems. In a related vein, a second positive feature of the business community was its ability to transcend clan divisions and rivalries. A third aspect that was frequently noted was the business community's ability to achieve what they set out to do. to that extent they epitomized what many referred to as `the Somali way.' The concept of capital investment could include not only large investors, but also smaller ones, particularly given that a large amount of money would need to be raised throughout the country.

Negative aspects of the business community's involvement focused on its probable lack of interest in addressing the needs of the poor, a fact that most likely would also limit its involvement in rural areas, although zakat and clan obligations of medical professionals were seen as a last resort for the poor. Sustainability, too, was a further concern. Should incentives be inadequate, there was little to keep the business community engaged in a health care venture.
d) Share options in a health insurance scheme.76 Complexities surrounding the possibility of purchasing shares in a health care system are considerable, beginning with the lack of any overt cultural affinity for these sorts of schemes. Nevertheless, the idea attracted a good proportion, though not a majority, of all the diaspora groups interviewed, and struck a chord with those who declared their intention to return to Somalia for regular or indefinite periods of time. Share options, however, may not be as alien to Somali culture as initially assumed. The aforementioned qaran, or the universal use of sholongo or hagbad 77 amongst Somali women, whether in the diaspora or in Somalia, reflects some of the principles and obligations surrounding individual and shared ownership. Even the newly established Coca Cola company has 399 share-holders, all Somali.

Micro-Insurance for the Poor

The idea of insurance for the poor was derived from discussions with Mike McCord, an expert on micro-insurance for the poor. Essentially the scheme would work as follows: Somalis would buy shares in an insurance company, which would be linked to a money transfer company because Somalis already trust these companies. The money transfer company would set up a separate insurance company, in which the funds invested in the company could not be used for the purposes of the remittance house. Somalis in the diaspora could contribute, as well as Somalis in Somalia (with money or through barter, such as a certain number of goats or camels). This share would provide membership in a health care scheme, and could be used in any of the affiliated hospitals or clinics. The share would be owned by the individual Somali and could always be sold to another person at a later date.

Somalis would still pay a fee for the health service required, but would not have to pay the fee at the time of hospitalization or when treated. There would be a certain amount of latitude in time allowed to pay (up to three months, for example), recognizing that a problem people have throughout the world, particularly the poor, is paying for medical services up front.

Businesses could provide contributions for their own staff, in a similar fashion to the `3x1' contribution of the HTA schemes. In the absence of any formal regulatory body, the business community's role would be fundamental, and some felt that clan elders could also be useful as a means to promote a sense of equity. The Somali money transfer companies have in fact indicated their interest in contributing to such a scheme, in addition to establishing charitable foundations.78 Other money transfer companies have already become involved in provision of some welfare services, for example, Amal Bank is examining the idea of investing in Galkayo hospital in north-east Somalia.

5. Payment and maintenance systems

The previous section focused on ways that Somalis believed would enhance a health service and the options for financing such a service. This section examines how they thought it could be maintained through the payment of fees or other means. In Somalia, as elsewhere, the cultural considerations that have to be taken into account when it comes to paying for health services are many. This would include Islamic charities, zakat, clan obligations, diaspora funding, fees and barter. The key issue in this context is the extent to which these modalities - potential as well as actual - were seen as adequate to cover the health needs for those Somalis who are poor and live in rural areas, particularly the pastoralists, as well as the wealthier Somali urban dwellers. The spectrum of actual and potential payment systems discussed can be subdivided into at least three categories: a) clan obligations; b) religious obligations; and c) payment innovations.

a) Clan and family obligations. `One must not forget,' said one Somali doctor, `that we would be denounced by our community if we ignored the health needs of one of our clan members.' The doctor went on to say that most likely he would have to charge the patient, for the patient would find it demeaning not to be charged and would likely consider the service to be of a low quality. The doctor, however, would give him `extended credit,' with no anticipation of eventual payment. While this sort of obligation might meet the requirements of a small clinic or individual medical practice, it does not seem to offer much in the context of a larger hospital setting. Nevertheless, respondents did suggest that payment and clan obligations had to be part of any calculation about how Somalis could and would `pay' for health care.

Such clan obligations are certainly evidenced in terms of the ways that the diaspora assume their remittances will be used. Up to half of financial transfers are intended to meet the needs of individual and extended families, but a portion of remittances - though a percentage is difficult to identify - is used to pay for community health services. When it comes to payment for health care for the family, the role of the diaspora is crucial. Yet, the diaspora also regard such obligations as a considerable burden, an unpredictable obligation always hanging over their heads. to that extent, the issue of the sustainability of a remittance-dependent health system in anything but the short and medium-term (viz, up to seven years) could be problematic. Thus the concept of an insurance scheme that would be reliable, if possible, similar to that described above, found resonance among many Somalis.

b) Religious obligations. Doctors as well as members of Somali communities frequently refer to their religious obligations that, like the Christian tithe, compel them to give a portion of their income or wealth for distribution to the poor. Zakat, the third pillar of Islam, requires that 2.5 per cent of individual wealth should be redistributed annually, and doctors interviewed for the study suggested that this sort of giving could also be used for health care payments, though they noted that this would be done in an ad hoc fashion (as indeed already occurs) unless the zakat contribution was channeled through a charity dedicated to health care.

That this seemed to contradict those doctors' same assertions about patients' preferences to be seen to be paying for health services was not a matter that was explored, though most Somalis mentioned that charity is intended for the most indigent, who may be less concerned whether the service is `free' or not. The more important point within the general context of health care payments is that there are religious obligations - no matter how unpredictable - that do and should cover at least some portion of costs, assuming that the services are available.

The availability of health services has been - along with education - a major aim of Islamic charity, either indirectly through mosques, individual authorities or through Islamic NGOs. The amount of money that is spent on health clinics and health services (portions of which are attached to education programs) is unknown, but Somalis do acknowledge the important role that Islamic funds and institutions play in providing health care and covering related costs.
c) Payment innovations. `Somalis don't understand insurance,' said one member of the diaspora in Minneapolis. `Oh?,' was the quizzical response of one of the interviewers, `do you have and therefore understand insurance?' `Yes,' was the reply. `But aren't you Somali?' the interviewer countered. `And couldn't you therefore explain it to your family in Somalia?' While there are a host of difficulties that would need to be overcome to introduce an effective insurance policy system in present day Somalia that would provide inter alia a safety-net for the poor, it was interesting to note the issues that the concept of insurance as well as other payment innovations raised for Somalis within the country as well as within host countries. two innovations in particular were explored, partly at the instigation of the interviewers and partly by the respondents: insurance and micro-credit.

Insurance systems.79 Some respondents assumed that the business community in general might also see health insurance schemes as a possible lucrative business venture, and that such schemes would also be funded by the diaspora. How such schemes would be used to assist the rural as well as urban poor were never resolved, nor were such issues as the extent of coverage or the extent to which one might need to link coverage to specific health facilities. With regard to the latter issue, it is worth noting that in several sessions Somalis from different clans and regions suggested that health facilities may specialize in different types of care services and that insurance holders should have access to all of these. Further discussions with experts in micro-insurance, as noted above, and other health experts, would help to elucidate how such a program could work in the Somali context, including appropriate mechanisms and feasibility.

Micro-credit. Various respondents noted that to some extent money transfer companies already provided micro-credit: they make funds available for relatively reasonable fees to enable borrowers to undertake projects or deal with personal problems such as death costs or health. These, however, are normally tied to remittance clients, and are by no means part of a systematic approach to providing credit. There is, however, a cultural basis for doing so, i.e., hagbad or sholongo; and there, too, is the possibility that money transfer companies also might find a more systematic approach to the provision of credit a useful innovation in order to maintain customer loyalty, to enhance their perceived value by a broader community, including governments of host countries, and to fulfill their desire to become more like banks.

6. Quality control

The term quality control is used to describe the various areas where respondents felt that greater training, advocacy and education, and regulation were essential to the success of any Somali health care system. Their views are interesting not only for the issues which they identified, but also for the roles which they felt were necessary for the international community to undertake. In the context of the latter, it is important to note that little emphasis was placed generally speaking on the role of the international community as funders, and more on the expertise - educational, technical as well as regulatory - that international and non-governmental organizations could provide.

The most consistent themes that arose when discussing the development of a Somali health care service concerned aspects of regulation and training, more specifically, the improvement of medical staff, control over medicines and hospital management. Aspects of what might be regarded as `equity,' that is, assistance to the poor and assistance to rural areas were also mentioned under the broad rubric of quality control.

The concern that Somalis have about the quality of medical staff, more specifically doctors, was seen as an issue that can be addressed in three ways: a) greater training in Somalia for doctors, including provision of up-to-date courses as well as re-establishment of medical schools; b) revision courses and training for diaspora doctors and nurses in host countries; and c) accreditation of doctors through established Somali medical associations. With all these suggestions, the roles of host governments, international organizations and NGOs were deemed to be vital.

With regard to the quality of medicines, the diaspora in particular were appalled by the reportedly poor quality, out-dated and inappropriate medicines in the market place. They were equally as damning of the dissemination and use of such medicines. Here, again, they felt that the role of international actors would be invaluable in helping to ensure high standards. Similarly, there was considerable emphasis placed on the role of the international community to advise and give guidance on aspects of medical infrastructure.

When it came to issues of equity, particularly for the poor, there was an assumption that Somalia would need the continued support of the international community, certainly in the short term, though there were few indications that - other than clan obligations - quality assistance for the poor could be systematically assured.

Implications for the future

On the whole, the extensive interview process involving a wide range of Somalis left the interviewers with the assumption that there were many respondents already engaged in or enthused about promoting sustainable health care systems in Somalia. And yet, as the following chapter suggests, there are several key steps that need to be taken before one can fully embark down this road. Nevertheless as that chapter also explains, there are ways that the challenges of a Somali health system can be met far more actively and extensively by Somalis than is being achieved to date. That, at least, is the way that the Somalis see it.

Chapter 6: Conclusions, Implications and Recommendations

This study explores policy options for supporting welfare functions, in the short to medium term, when conventional government services are not available. Using the experience of the Somali people, including those in the diaspora and the business community, the study sought to determine if the interaction between the business community, the diaspora and clan structures could provide the basis for a sustainable health system.

The conclusions of this study - based on extensive interviews with Somalis within and outside their country, and an extensive review of literature on the role played by diaspora in other countries - are mixed. The proposition depends in no small part on a definition of `sustainable health systems'. Hence, it is more reasonable to assume that the theme has more relevance from the perspective of clinical rather than public health care services.

As fundamental as the definitional issue, is that concerning the stimulus for innovation. The research team, contrary to their original intentions, had to pump prime respondents to get them to think about `sustainable health systems' outside a conventional governmental context. Once `primed', however, there was consistent enthusiasm for various alternatives among the diaspora, though much greater skepticism on the part of those interviewed in Somalia. This difference is interesting when considering the possible influence that the former might have over the latter, or, in other words, the extent to which the experiences of the diaspora as well as its resources might affect the attitudes of those who have remained in Somalia. These two issues underline the conclusions and the study's main recommendations. Conclusions

1) In the context of global perspectives, the study reflects a burgeoning interest in the relationship between the diaspora and their home countries across the world. Its relevance to the study is that:
a) The impact of remittances from the Somali diaspora on Somalia is one of the major factors - if not the single most important factor - in ensuring the livelihoods of the majority of Somalis in urban and, to a lesser degree, in rural areas. This fact, however, raises concerns about `remittance dependency' and has been mentioned by a number of Somalis.
b) Diasporas can influence the use of remittances to a degree, and would potentially be interested in investing a small portion in a health insurance scheme for relatives in Somalia. This challenges the view of most development economists that one should not touch family remittances. In this study, the researchers found more flexibility concerning this fundamental point among the diaspora. Nevertheless, those interviewed in Somalia expressed reservations about the diversion of such resources away from their present uses.
c) The money transfer companies, built entirely on trust, and often established after proven success in running a normal business (as in the Dahabshiil example), have highly competitive prices and general accessibility or ease of access, which ensures the effective functioning of this system.
d) A few international organizations have already been experimenting in the area of the use of collective remittances for development in Somalia by dedicating fund that support remittance partners or partner with collective remittance programs. These organizations include USAID, UNDP, the European Commission and the World Bank.

2) After almost 13 years without an internationally recognized government, Somalis have developed a range of `public services' that in normal circumstances would require the active involvement of government, e.g., regulatory overview. These include three Somali airline companies, several telephone companies, abattoirs and hospitals. The conclusions arising out of this analysis are the following:
a) The diaspora and the business community actively invest in projects of mutual interest, and are willing to take risks. While there have been various initiatives that have failed, those that have succeeded have proven to be profitable. Financial incentives for innovation appear to be a driving factor.
b) Despite the importance of financially-based incentives, Somali businesses have an emerging sense of `corporate social responsibility'. Local NGOs are making greater attempts to seek resources from local businesses and Islamic charities.
c) Clan structures and elders can have a positive impact on such ventures by serving as mediators, arbitrators and conduits between contending interests. Their weaknesses are regarded, however, as great as their strengths, since frequently clans are seen by Somali investors as potential constraints on the smooth functioning of business and some `public' services. Such constraints include job-seeking and `bribes' for clan members.
d) While the diaspora have proven to be vital in terms of supporting family structures and livelihoods, at the same time they have often been poorly informed when it comes to projects intended to support community needs. They appear not to know how to prioritize or evaluate project proposals.
e) The most successful projects have been local ones, or wholly clan-based, or normally in geographic areas that proximate clan demarcations. There are few, if any, attempts to develop `nationally'-based ventures, and even phone systems, airline companies, soft-drink manufacturing and the hawala networks started out as locallybased companies, which later expanded throughout the country.
3) The international community, though increasingly sensitive to the implications of remittances on their own work in Somalia, frequently commented on the lack of information about the volume and use of remittances. In part this might explain the seeming gulf between the activities of international organizations and remittance-sustained innovations. It might also reflect a certain organizational disinclination to change approaches and procedures that would accommodate the consequences of a business-oriented and remittance culture.
a) The international community will in the foreseeable future be the principal if not the sole provider of conventional public health care services, e.g., vaccination programs, though there may be an increasing number of opportunities for locallybased Somali ventures in public sanitation and water management, for example.
b) An estimated 50 to 60 international organizations are supporting health services in Somalia. Several key organizations are Islamic charities that work very closely with local authorities, Somali-based religious groups and local schools. The success of these Islamic charities reflects the extent to which they are embedded within local communities, their unique working practices and their excellent understanding of Somali culture.
c) Despite instances at the global level in which western international organizations have supported remittance-based welfare initiatives, including the provision of health care, there is little semblance of a coherent or sustained strategy by any individual or group of international actors.

4) There were few Somalis who envisaged a `national' sustainable health care system. Some thought that only a private health care system would work, with an eventual government serving as a regulatory body. That said, as the Somalis looked to the future of health care within their country, the following conclusions can be drawn:

a) A large majority of the Somalis interviewed for the study felt that the only way for sustainable health care to succeed in Somalia was to have private medicine. That said, their conception of health care was principally focused on clinical rather than public health concerns. The diaspora had supported and would continue to support health care as: a charitable obligation to local communities, a service that they would require if and when they returned to their homes, and essential for providing for families in ways that were available and affordable.

b) A smaller percentage felt that there could be no health system without a government, while a few suggested that the principal arm of health care had to be `public' in terms of publicly run hospitals, clinics, or they talked in terms of a blend of the public and private, but did not suggest within which type of institutional framework such a mix would operate.

c) A growing number of Somali medical associations are being created among the diaspora as well as in Somalia, mainly for doctors but also for nurses. These associations reflect a generally consistent desire on the part of Somali doctors in the diaspora to return to their home country, and in so doing, to expand local medical care and facilities, while Somali doctors in Somalia are attempting to harmonize practices and training standards.

d) There is a general lack of medical training throughout Somalia, although some international organizations provide a modicum of assistance. At the same time, many medical professionals in the diaspora also require refresher courses and retraining.

e) The distinction in quality and access to services between rural and urban services was to some extent blurred due to: i) the locations of a growing number of clinics, health practices and, in a few instances, hospitals that could provide assistance to both, ii) cultural assumptions about what one needs medical assistance for and where it should be provided, viz, traditional health practices as well as home-based care, and iii) the mobility of rural and pastoral communities in terms of seeking assistance in villages, towns and cities with health care facilities.

f) Various schemes were considered feasible for funding health care systems, though there was no dominant view about the way forward. The most consistent proposals were: i) greater support for health care facilities by the diaspora; ii) donations, or matching funds in the tradition of the Mexican Home Town Associations (with the `3x1' contributions made by the Mexican federal, state and local governments to development projects). Matching funds in this instance to be provided by the money transfer companies and potentially international donors based on a percentage of remittance fees to fund health care; iii) investment by the Somali business community; and iv) joint partnerships between local communities and authorities, the diaspora and the business community. Each of these proposals reflected patterns of investment that are already taking place around the country, and could be expanded. There appears, however, little push to promote such developments, either from the international community or from Somalis within or outside the country, and this may simply be attributed to the tendency over the years of state collapse to focus more on the needs of home or local, clan-based communities, rather than at the national level. In addition, there is the obvious reason, which is that there is no national government, nor have international organizations provided a national framework.

g) Paying for individual health care was seen as closely linked to remittance schemes. At the same time, there was a degree of interest among the diaspora in insurance schemes that could be paid through remittances, or as a separate business undertaken, for example, in partnership with the money transfer companies. Somalis in-country were far more skeptical about such innovations. The prospect for microinsurance schemes, related to micro-financing, had appeal in some quarters, but would require the active intervention of the money transfer companies as well as a deeper understanding of how they would function (which could be provided through consultations with international experts on micro-insurance). General Recommendations Four fundamental issues stem from the study's findings and conclusions. First, there are significant, though piecemeal, efforts by Somalis to date to establish various types of health care facilities, including clinics, hospitals and regional health boards. Second, Somalis in the diaspora were very receptive to a wide range of ideas about ways to promote welfare services such as health care in Somalia. Third, if donors wish to promote and foster the potential interest and commitment of Somalis to develop a health care system, they need to move away from provision of assistance per se to facilitating assistance through technical means and by adapting their programs to take into account other current realities (i.e., what Somalis are already doing). In other words, there needs to be a greater awareness of Somali innovations. Finally, it is clear that while the international community is increasingly interested in the relationship between remittances, the influence of the diaspora and development in Somalia, insufficient attention has been made to develop a strategy - sectorally or more broadly - to do so. With this conclusion in mind, the results of the study lead to the five sets of recommendations, many of which could be implemented in conjunction with diaspora groups and civil society, business and clan counterparts:

1) Fill the information voids. There is a considerable lack of information in many key areas that inhibit the development of effective Somali-based welfare systems. These gaps need to be filled, and hence require:
a) Mapping exercise. Comprehensive analysis of the types and levels of health services available throughout Somalia is needed - in other words, those managed and sponsored by the international community, by Somalis and by international Islamic NGOs. Such a survey would also attempt to determine sources of funding and the sustainability of such funding. Ideally such an exercise could also be expanded to cover education and other social welfare issues.
b) Capacity assessment. Establish and continuously update a data-base on the number and quality of medical practitioners in Somalia and in the diaspora. This could be achieved through a combined effort of international actors, Somali medical associations - inside and outside the country - and key diaspora groups.
c) Health coverage and user analysis. Recognizing previous surveys and assessments, a general survey is nevertheless needed to test key assumptions about the use of health care in Somalia. This survey would seek to determine, inter alia, the extent to which private clinics relieve pressure on hospitals, enabling the latter to serve the poor more effectively, the types of medical needs, access of rural and pastoral communities to health services, and impact of clan and religious obligations as a safety net for the poor.80
d) Payment systems. Undertake a further study on alternative payment systems for health care coverage. This study would analyze, among other things, the potential for micro-financing and micro-insurance schemes in the Somali context.81 2) Promote dialogue. Somali respondents appeared very responsive to a variety of entrepreneurial ideas as well as suggestions about ways to deal with the health needs of their families and communities in Somalia. There are, however, few opportunities to discuss such `visions' with more experienced experts, and little incentive for the diaspora to think in different ways. There is a clear need to promote dialogue with a very clear objective along the following lines:
a) Community discussions. Through various diaspora modalities, such as mosques, community organizations, the internet, and the media, discussion could be facilitated on the various health initiatives that could work in Somalia. These discussions could focus on the possibility of initiating pilot projects.
b) Money transfer companies and social responsibility. Organize a series of discussions between host governments and key money transfer companies to examine ways to facilitate the efforts of interested groups to promote Somali health care.
c) Medical associations. Facilitate discussions with Somali medical associations within and outside the country about training, retraining and `refresher' programs that would enhance the capacity of medical practitioners. Structured dialogue sessions should also discuss issues of regulatory health standards for medical practitioners and for pharmaceutical distribution. This could be done in conjunction with who and UNICEF, as who has recently supported training of doctors, while both organizations are examining ways of working more closely with the SMAs.
d) Use media in Somalia and in diaspora communities. There appears to be a general lack of discussion and exchange of ideas about what a Somali health care system - local as well as national, primary as well as public -- might look like. One way to promote such a dialogue would be to determine whether the well-established media sources in Somalia - including television and radio and internet - as well as those run by the diaspora in host countries, might be interested in promoting debates and discussions on Somalia's health future. The international community could support such efforts at dialogue through relevant health care experts. The UN's IRIN might also be interested in being used for this purpose.
e) Promote Islamic NGO-SACB discourse. The SACB should take the lead on actively promoting discussions and exchange of information with Islamic charities in Somalia and with those groups in various countries that support them. One would hope that these sorts of discussions could result in some form of joint activities, prevent overlap and duplication, improve needs assessments, and importantly, enhance the lives of Somalis. It may also be the case that the SACB might want to consider adopting some of the processes of the Islamic charities that have been more successful in Somalia.
3) Facilitation. The theme that underlies all the report's recommendation in general is the need to work with the Somali diaspora and Somali civil society in ways that aligns the initiatives of the Somalis and the work of the international community more closely. The recommendations noted below are also consistent with that theme.
a) Analysis of support mechanisms. Following from 1.d, above, particular effort needs to be made to determine ways that the international community can support Somali-driven health care initiatives. The emphasis most likely should be on technical support, since there is concern that support mechanisms that are based on direct financial support will undermine the nature of the Somali initiatives, including loan schemes for the provision of medical equipment and training.
b) Review tax support schemes. While some governments of countries that receive large amounts of remittances provide tax incentives, attention should also be given to ways that governments of host countries can promote remittance flows, including those for health services, through tax deductions, transfer cost reduction and other related measures.
c) Promoting regulatory frameworks and codes of practice. As noted earlier in this report, there are a number of efforts to establish regulatory frameworks and codes of practices in certain areas and institutions around Somalia. This sort of support is essential, and ways - linked to the issue of dialogue - should be considered to intensify such efforts. 4) Training. As in so many other aspects of Somali life, the issue of training and education looms large, both among the diaspora and in Somalia.
a) Refresher and retraining courses for diaspora medical practitioners. This issue was raised among various Somali medical associations in diaspora communities, and was felt to be a way to strengthen professionalism in Somalia. However, the issue is very sensitive, since these courses might be seen as a means by which governments promote return, and exclude Somali medical professionals from host country medical systems.
b) Refresher and training courses for Somali professionals in Somalia. There are purportedly a cadre of doctors and nurses in Somalia with medical qualifications, but who have not practiced or been exposed to medical advances for some time. Refresher and retraining opportunities could be offered in various centers around the country.
c) Training in data collection and statistical analysis. This area of training is an essential aspect of preparing for more professional health services at any level in the country. Various initiatives that have been undertaken by the international community, though none with an overall emphasis on a health strategy.

5) Pro-active strategy development.

a) Inter-institutional strategy development. Specific attention needs to be given to developing an overall strategy for the provision of Somali health care. This strategy should be linked to the recommendations outlined in 1 - 4 above, and reflect active interaction between the Somali diaspora, civil society, the business community and clan elders as well as relevant local authorities and Islamic charities. The SACB could serve as the forum for this initiative.
b) Country comparative analysis. Various countries have experimented with ways to fund health care and to ensure safety nets for the poor, such as in the case of Ghana and its health insurance scheme for diaspora Ghanaians. A concerted effort should be made to identify such mechanisms, and to determine their applicability to Somalia's present situation and as options for a future Somali government to consider.
c) Pilot projects. In parallel with an inter-institutional strategy, there should be a small number of health care pilot projects - expanding on existing projects or developing new projects - in which the main components of an integrated strategy could be tested. These main components would `test' some of the key elements noted in recommendations 1 - 4.

Proposal for USAID Follow-Up

An agenda for action

The results of the USAID funded study on social facilitation, development and the diaspora suggest that assistance to Somalia could be maximized if it was linked more effectively into development-related activities in which Somalis, themselves, are engaged. Health as well as education are areas in which the combined efforts of the diaspora and business communities in many parts of the country have made a considerable impact. Unfortunately, however, international assistance runs parallel to Somali social sector initiatives, and very rarely intersects.

This agenda for action proposes measures by which `the Somali way' - if supported effectively - could have a positive impact upon the welfare of many Somalis. The cost of such support would be minimal, and the collateral benefits considerable. The former would depend on using what already exists more effectively; the latter would be reflected in new approaches to support peoples in states where governments lack the capacity or will to assist their populations.

Six steps for USAID

1) Information is the key. While information gathering mechanisms exist, there still are large gaps in available knowledge about the health care and health facilities situation in Somalia to support Somali-driven initiatives effectively:
a) Use existing mechanisms e.g., SACB Health Committee, to address the unknowns in the Somali health sector, including, e.g., mapping of existing health facilities, health coverage and user analysis.

2) Foster consultative processes and dialogue. When encouraged, the Somali diaspora as well as Somalis in-country are enthusiastic about exploring different ways for dealing with health care. Dialogue and consultative processes should be encouraged, and the likelihood is that they will lead to direct Somali action:
a) Promote discussions on ways for Somalis to provide better health care through Somali-based radio and television media.
b) Promote discussions through international channels, such as the BBC Somali Service;
c) Sponsor discussion groups, e.g., through the recently established Somali Medical Association in Columbus, Ohio, as well as a wide range of Somali support groups in the United States on the future of Somali health care, both of the physical and the virtual variety.
d) Dialogue between remittance houses, development agencies and interested Somali groups.
3) Use existing mechanisms. There are existing institutions that could be used to undertake several of the tasks noted above. USAID is well established in most of these areas, and hence, should consider how best these could be used to meet the sorts of requirements needed to support Somali social welfare initiatives:

a) The Somalia Aid Coordination Body (SACb) and the UN Development Programme are both heavily engaged in issues of health and remittances. With guidance, these institutions would be able to assist in providing the data and information as well as support efforts at expanding dialogue and consultative processes.
b) The Good Donorship Forum, in which USAID participates, could explore the viability of the Somali initiative, and the OECD/DAC could be linked into aspects of the work needed to support Somali-driven health initiatives.
c) The Integrated Regional Information Network (IRIN), supported by USAID, is but one of several mechanisms that could assist efforts at promoting consultative processes and dialogue.

4. Refocus technical assistance. Rather than focus resources solely on capacitating international governmental and non-governmental organizations, a portion of present expenditure should be used for technical assistance for Somali-driven health initiatives:
a) Training and retraining are the factors that are most in demand when it comes to health care systems in Somalia. Here, is but one more example of ways in which technical assistance could have a major impact on Somali-driven health care initiatives. Such technical assistance should be provided in the US for Somali medical professionals interested in returning home permanently or for a fixed period, as well as in Somalia, itself.

5. Relate more with Islamic charities. There is probably far more support being provided by Arab states in the south of Somalia than had originally been assumed. Much of this is for direct investment, but also a large portion is reportedly funneled through Islamic NGOs for social services, including health and education:
a) Efforts should be made to establish means for exchanging information about the work of Islamic NGOs and others in order to explore areas of potential collaboration and avoid duplication and overlaps. no matter how tenuous this suggestion might appear in the present environment, there are indications from a few Islamic NGOs that they would seek greater dialogue, and these openings should be explored more systematically.

6. Pilot projects. There are two or three areas in Somalia/Somaliland where USAID should consider establishing pilot projects. The purpose of these pilot projects would be, among other things, to ascertain the impact that these projects would have on the urban and rural poor and rural populations in general:
a) Pilot projects would require agreement with relevant local and diaspora groups, technical assistance and monitoring capacities.

Appendices:

A-I: Project Proposal

Social Facilitation, Development and the Diaspora: A Proposal for USAID on Sustainable Health Services

A summary

The time is right to experiment with new approaches to development. In many of the poorest countries, conventional state structures and traditional government strategies fail to serve as effective conduits for social, economic and institutional development. The overall objective of this social facilitation initiative assumes that - until governments demonstrate greater accountability and capacity - essential social support for those in need requires alternative delivery systems. The immediate objective of the project, ie, the project assessment phase, is to explore new techniques for providing health care through a network comprising the diaspora, the business community and local structures in weak or collapsed states. As an exploratory initiative, it is concerned with testing the validity of key assumptions and the viability of effective delivery. The project assessment phase will take five months to complete, with a project budget of $ 98,650. Based upon the conclusions emerging out of this exploratory phase, the project will recommend steps that should be considered to undertake an experimental implementation phase designed to provide health care through the proposed form of social facilitation.

Background

The following proposal arises out of discussions held in July 2002 at USAID concerning a project entitled, Somalia: An Operational Map for the Future. During the course of those and subsequent discussions, two important issues were raised. The first centered upon USAID's concern that Somali healthcare was becoming permanently `institutionalized' through USfunded private voluntary organizations [PVOs], and that there seemed few prospects for eventual Somali ownership. The second issue concerns the experimental nature of a project designed to provide services systematically in a situation in which no conventional state structures exist. The assumption in this instance is that the lessons learned from this project will have practical utility in other situations where normal governance institutions do not exist.

Somalia, and to a lesser extent the region called Somaliland, has no formal and official structures that can provide health care services. Since the collapse of the Syad Barre regime in 1991, there have been no government systems that have had the resources or institutional capacity to provide even the most basic forms of health assistance. In the absence of such structures and systems, international private voluntary organizations and United Nations agencies have offered a range of services, from vaccination programmes and MCH to various levels of surgical intervention, frequently with the aid of local counterparts.

The results have in many instances been impressive but all to often limited in their reach and consistency. They reflect an approach that responds relatively well to health crises, eg, tuberculosis, but not so much to providing preventive medicine. Their coverage also tends to be geographically restricted to areas affording relatively easy access and security. Despite all the efforts made to assist the people of Somalia, the health standards of the Somali people remain the second worst in the world.82

While those Somalis who live in Somalia have little medical protection as a whole, there are qualified medical doctors who still practice in the country in private as well as PVO and ICRC sponsored facilities. At the same time, the Somali diaspora, themselves, representing in percentage terms one of the largest migrant communities in the world,83 provide considerable cash and in-kind support for their extended families in Somalia. Estimates suggest that remittances equal four to five times the amount of official development assistance [ODA], the former being in the region of $500 to 700 million.84 More importantly for this project, this level of remittances - while fluctuating with economic trends in the developed world - would nevertheless appear to be relatively stable over the long term.

The diaspora at the same time also know and benefit from health services provided in their host countries. There is a variety of such services, spanning a range of private and public schemes. The benefits of an institutionalised approach to health will not in any event have escaped the attention of Somalis who now have benefited from such services in various Western and Gulf countries over the years. At the same time, based upon discussions with Somalis in the United States, Denmark and the United Kingdom, there would seem to be a degree of frustration on the part of the diaspora that a significant proportion of remittances is spent on commodities that do not provide the intended support to families such as the traditional stimulant, chat or qat.85

As evidenced by health initiatives in Galkayo and Merka, the Somali diaspora are already willing to support health facilities through remittance payments. Such support, however, is not provided systematically or consistently, but rather in response to very specific crises or for particular types of medical equipment. The challenge is therefore to see whether there might be incentives to have the diaspora promote and support longer term health care over time.

In so saying, one area that relates to the issue of possible incentives is that of improving the legitimacy and transparency of remittance procedures and the `xawaalaad' process.86 Only recently the Somali Financial Services Association was formally established, with one of its avowed objectives to seek ways to foster greater transparency between the diaspora, the remittance houses and host governments. to what extent, one must wonder, can the need for sustainable medical services, the need for greater transparency and the need for incentives to ensure both be linked?

Project proposal

The project is designed to test the proposition that sustainable health services in Somalia can be developed based upon the triangular interaction of the Somali diaspora, the business community and clan structures. The assumptions underlying this inter-relationship are that [i] common functional interests already exist amongst these three sectors and can therefore be used as the basis for providing social services; [ii] the experience of the diaspora and the impact of remittances will fuel social service facilities in ways that are more cost-effective and sustainable than those provided through conventional UN/PVO/NGO aid programmes; [iii] such social services will become self-sustaining, significantly reducing conventional foreign aid support for basic health services; and [iv] that there may be an important link between fostering remittance transparency and using remittances for sustainable medical support.

In the first instance, the project is designed to test the veracity of these four assumptions. Secondly, depending upon initial findings, the project will propose pilot initiatives to determine the merits of more focused investment in this social facilitation approach.

[i] Common functional interests. Key to the proposed social facilitation initiative is the assumption that there is sufficient commonality of interests amongst clan structures, the diaspora and the business community to provide consistent health services throughout many parts of Somalia. It is apparent, given commercial developments in Somalia such as the telephone, soft drink and even the qat industry, that Somalis from abroad are willing to invest in enterprises that are profit driven. They, too, are also willing to provide assistance to hospitals and other medical facilities, though normally on a one-off basis. Clan structures, geography and political differences rarely prove to be practical commercial constraints. Closely tied to this assumption is the belief that a nascent medical base already exists, consisting of doctors and health professionals who operate in various urban centres in Somalia, those who practice outside the country and may wish to return and those who can be `trained up' for essential health care functions.

[ii] Utilising the experiences of the diaspora. There can be little doubt that diasporas as a political phenomenon, particularly in the late 20th century, can be potentially as divisive as they can be positive.87 In this instance, the project's assumptions to be tested are two-fold. The first concerns the premise that the Somali diaspora who have considerable experience in the developed world are frustrated at what they often feel is the misuse of remittances on commodities, ie, qat, that provide no perceived benefit to their immediate families and relatives. Linked to that premise is that the diaspora would welcome a system that could provide some assurance that their funds would be wisely spent upon social benefits to their families, and that remittance flows could be used for such purposes. It also assumes that the reach and the interests of the diaspora would not solely be focused upon urban areas, and that clan structures and their inherent tradition of social outreach would provide for broader health cover than the conventional foreign aid-supported facilities to date.88

[iii] self-sustaining social services. The project comes with a caveat: this triangular network initiative will require much greater clarity as to which types of health services will be provided. One also will have to bear in mind that in the final analysis all effective health systems require some modicum of tax-based state support, a factor not foreseeable in Somalia's immediate future. That said, the assumptions underlying the proposed approach to health services are that the health services provided at present - while for the most part basic - can be improved both in terms of content and coverage through the triangular network scheme. In that regard, the emphasis is upon improved and more sustainable, and these in turn reflect critical assumptions that this project would explore.

[iv] transparency incentives. In December 2003, the Somali Financial Services Association was formally constituted, reflecting the acknowledged need for xawaalaad services to be more transparent in their activities. At the same time, there is also considerable recognition given to the importance of remittances as means to provide social safety nets throughout Somalia. The inter-relationship between the two needs to be explored, and efforts need to be made to see whether incentives could be used to guide the diaspora's remittances towards objectives that need to be more sustainable such as medical services. The sorts of incentives that might be considered span a range of possibilities, and it is translating this range of possibilities into potentially practical proposals would be one important outcome of this project.

Project methodology

The methodology to be used to support this project consists principally of survey and interview work and analysis of health care provision in Somalia at present. After recent discussions with a representative from the European Commission's Somalia Office, it is clear that some very important background work that relates to this initiative has been done by the EC-funded Somalia Health Sector Coordinator and by the EC's Office responsible for governance programmes in Somalia. Hence, a portion of the background research can be reduced, though there are still four broad dimensions that need to be explored:

[i] survey of Somalia diaspora in four countries [viz, selected locations in the United States, the United Kingdom, Germany and Denmark, in order to ascertain remittance expenditure patterns and expenditure preferences;
[ii] interviews with relevant government officials from the United States, the United Kingdom, Germany and Denmark;
[iii] interviews with sample of Somali diaspora in countries noted above in order to determine perceived interest in and feasibility of proposed social facilitation initiative;
[iv] interviews with selected community-based organizations, clan elders and business representatives in Somalia, the Gulf region and also in Europe and the United States as well as representatives of money transfer companies to assess views on proposed initiative;
[v] interviews with selected representatives of the Somali Financial Services Association who represent remittance houses and with selected government regulators, both to ascertain possible links between transparency incentives and support to medical services;
[v] interviews with relevant international organizations [including the World Bank, World Health Organization, United Nations Development Programme] to enlist views about project feasibility.

The second component of the methodology will entail analysis of health care provision presently provided in Somalia. This analysis will depend principally upon health care reviews provided through the Somalia Aid Coordination Body [SACB], the EC-funded Health Sector Coordinator and discussions with relevant international and non-governmental organizations and, as previously noted, discussions with community leaders, recognised local authorities, the diaspora and clan representatives.

Project output

This project is intended to explore the prospect of providing social services for the people of Somalia through a triangular set of networks, as outlined in the discussion above. Yet assumptions about the network, itself, the interests and dynamics of the diaspora, the nascent capacity of local medical services, the potential outreach and the consistency and sustainability of remittance-based services have to be carefully explored.

A preliminary project assessment, principally reflecting an analysis of the central assumptions that would underpin this social facilitation initiative. The analysis of the proposed project's central assumptions would be encapsulated in a report that would focus upon the findings of extensive survey work with the diaspora, clan leaders and other relevant authorities in Somalia and with members of the Somali business community, both within and outside the country. The analysis would include the views of interested governments and international organizations. In this regard the feasibility of transparent remittance mechanisms would be an issue of considerable concern as would be the accountability of local remittance houses. The project report will be approximately forty pages, excluding annexes, and will provide a series of specific recommendations - depending upon its findings - about specific steps that need to be considered if an experimental implementation phase is to be considered.

A-II: Guide for Interviews

Draft: 8 June 2004

DIASPORA AND DEVELOPMENT: GUIDE FOR INTERVIEWS/APPROACH

This is an exploratory study that is exploring some concepts and testing some assumptions. The study will improve our knowledge of the `development' process in Somalia, with the overall aim of assisting and facilitating that process. The study faces several challenges in collecting information.

The subject of the enquiry - how diaspora remittances are and can be used in Somalia - is a sensitive, and something that informants may be reluctant to discuss in depth. There is international concern (particularly among Western governments) about the laundering of money through Somalia to fund terrorist activities. Among Western financial institutions there is concern about working with Somali money transfer companies.

Donor interests in the study will be informed by concerns about how to deal with a `stateless' population, a potentially `terrorist haven', money laundering, small arms trade, regulation of informal financial institutions, migration and asylum policy, interests to reduce donor aid, (remittances may be seen as a substitute for aid financing), a concern with `qat'.

Somali remittance companies have often always been reluctant to provide information about their activities and the resources that they handle. By their nature remittance systems are designed to avoid regulation. The informal nature of their activities means their records and knowledge about the transactions that they deal with can be poor. In the current climate they may be more reluctant to provide information for fear of coming under suspicion.

There is currently a lack of good, empirical research data, particularly on Somalia. The `informal', `grey', and `illicit' nature of the remittance economy means that much information is likely to be an educated guess rather than factually based. Somalis may be reluctant to divulge information about remittances. They may be (not unrealistically) suspicious that there is an intention among donors countries in substituting aid with remittances. In the same way that Somalis will not say how many camels they own, they may be unwilling to divulge information on personal finances. And why not - we would be equally reluctant.

Finally, some Somalis are capable of talking about anything if they see there is something to gain. no doubt we would find many willing to talk about flower arranging if that was the subject of enquiry. Triangulation of information is there important.

Approaching Somalis

Given the potential sensitivities, the following might inform our approach: Make it clear that this study is an initiative of RK, of KCL International Policy Department - not the Centre for Defence Studies - former Resident Coordinator. Play up the teams experience and knowledge and interest in Somalia.

Avoid, where possible, advertising that the US funding of the study. If this is unavoidable, emphasize that it is USAID funding, rather than state-department, or that there are multiple donors for the study.

Emphasize that this is an `exploratory study', seeking to understand the role that remittances are playing in reconstruction and development in Somalia. This includes the rehabilitation of social services.

Approach the subject of health provision/systems, by discussing how Somalis in Somalia currently access social services, including health and education. also how they access health in asylum countries, what they think maybe transferable to Somalia.

Test some ideas (e.g. possibility of nationally or locally run systems, interests in a `health tax' on remittances, health insurance), with the purpose of generating broad discussion and ideas on how remittances might be used to finance health services.

Dedicate time to interview women, as Somali women are the main senders of subsistence remittances. They may have the best sense of family health priorities.

It is important to be alive to generational and gender differences.

Sources of Information

The primary sources of information for this study will be key interviews and a review of appropriate literature. It is neither practical nor necessary to undertake a statistical survey for this study.

Key Informants

Key informants Type of information

Somali remittance companies Scale, sources, past and future trends in remittance flows to Somalia.
How the remittance system works
Changes in nature of remittance companies.
Constraints faced by companies and individuals
Relations between remittance companies, business, charities in Somalia.
Interests in the study.
Somali diaspora organizations Nature of the organizations
Nature of interest in Somalia
Current activities in Somalia
Perceived priorities - in Somalia and outside
Relations with other Somali diaspora organizations
Involvement or interest in health provision
Migration patterns
Somali women in the diaspora Scale of their remittance contributions
Constraints in providing remittances
Trends in remittance flows.

Priorities

How do Somalis access health in host country

Somali professionals What kinds of professional skills exist in the diaspora
What Somali health professionals exist in the diaspora.
Somali elders
Unclear that elders have a specific function in the remittance economy, or in running of services in Somalia, so this is something to explore.
Somali NGOs Involvement in health sector.
Sources of funding.
Somali businesses Examples of new business adventures in Somalia.
Understanding the investment by Somalis in the diaspora.
Identify examples of business support or interest in the health sector.
Somali regional authorities
Their formal involvement in the health sector.
Attitudes to remittances and the diaspora.
Legitimacy within the diaspora.
International financial institutions
What is their interest in remittances.
Academic researchers
Frameworks for understanding migration patterns, the economics of migration and remittance flows.
Empirical data on remittances and migrants in Somalia and elsewhere.
Knowledge/examples of other countries/ contexts.
Policy issues.
Health economist/ public health professionals
Financial requirements for running a health system/ different types of health systems.
Sustainability issues.
Basic minimum needs for a health system.
UN agencies
Current health activities/ policy in Somalia.
Value of current aid investment in health.
Experience of funding and managing health system.
Existing knowledge of and activities with remittances, diaspora organizations, remittance companies.
International NGOs
Current health activities/ policy in Som Existing knowledge of and activities with remittances, diaspora organizations, remittance companies.
Donor governments Existing knowledge of and activities with remittances/ remittance companies.
Documentation
QUESTIONS
The proposal is based on a series of assumptions and part of the research will therefore involve testing those assumptions. The following are key questions and/or issues that can form the basis of discussions with interviewees.

Dependency?

The proposal starts with a concern that Somali health care is becoming institutionalised (dependent) on US funded PVOs. This exaggerates the importance of USAID. There are bigger donors than USAID. also there is evidence since the 1990s, that a majority of Somalis buy their health care from the market.

There is a real concern amongst Somalis in the diaspora and aid agencies that Somalis in Somalia are becoming dependent on remittances. There is some evidence that Somalis is the diaspora are looking for ways to avoid their obligations to send remittances to their relatives in Somalia. This may impact on remittance flows to Somalia, but may also encourage Somalis to look at alternatives to the current practice.

The diaspora

who are the Somali diaspora e.g. those in the West or in Africa or the Middle East? Where are they concentrated? do they differ in different parts of the world? What is their social status/ class in different countries?

What is the size of the diaspora?

What are their interests, priorities?
who sends remittances?
Are the diaspora concerned about the way their remittances are currently being used in Somalia?
What capacities exist in the diaspora [especially medical/health]?
Is there interest among Somalis for supporting health systems?
Role of Somali charities
Role of remittance companies?
Recipients
How are remittances utilized?
who sends/ receives /benefits from remittances? Has this changed over time?
Is there a gender dimension to be aware of, in terms of sending and receiving? [There is evidence that women are the main senders].
who sends and who spends?
Do all Somalis receive remittances?
Data on what people currently spend on health?

Economic trends

Trends in remittances [e.g. have contributions increased or decreased]?
Have the purposes for sending remittances changed [e.g. from supporting the clan to supporting the family]?
Which part of the economic system would be more appropriate to tap into [e.g. the $100 per month subsistence remittance, or the businesses]?
Information on changes in diaspora business engagement in Somalia?
What role does zakat play in meeting health needs in Somalia?

Health needs in Somalia

These are questions to be asked in Somalia and outside.
How do Somalis currently address their health needs?
What health system(s) exists?
How well does / do they work?
How is it/ are they paid for?
What do the diaspora contribute to health provision now [we know they contribute to emergency medical provision]?
What does aid contribute?
What are the priority health needs in Somalia?
What are the priority requirements needed to address health needs. [stopping khat may do more for improving health than any health intervention]. Is more money/ funding the solution?

A Future Health system

What kind of health system is envisaged and what is feasible - a national one or one specific to their locality?
What would remittances pay for? Would it do the same as aid, or be an alternative?
How could rural areas be covered?
Would it be preventative, or treatment based, primary or tertiary?
Would it address common or acute problems?
Would those Somalis who did not receive remittances have access to the health system?
Would women get equal access to health provision? [Some argue that lack of priority given to female health care is responsible for high maternal mortality].
Are there health professionals outside Somalia who want to return?

Common functional interest

Is there interest among Somalis in Somalia and in the diaspora and in the business community, in working together to support health services in Somalia?
Are there communal functional interests in diaspora, clans, business community in supporting social services.
Is the interest in localized services or regional or national systems?

Sustainability

Is the current health system not sustainable?
Is it possible to have a sustainable system, that does not rely on tax-based support? [what per cent of taxes goes on health, what is realistic to expect?]
What is the cost of running different types of health systems and are remittances adequate?
Where will human resources come from and who will pay and train them?

A-III: Interviews

Somali Interviews:

Members of the research team interviewed over 300 Somalis in Denmark, Italy, Kenya, Somalia, Switzerland, the United Kingdom, and the United States. They were representative of all the Somali clans and regions, and came from a variety of professional and educational backgrounds.

Meetings were also held with representatives of the following Somali organizations and businesses:

* Academy for Peace & Development
* Amal
* Dahabshiil
* Doses of Hope
* Gollis College
* Hargeisa University
* Horn Relief
* ICD & RHB
* Institute for Practical Research & Training
* Mogadishu University
* Mustaqbal
* Penha
* Regional Health Board, Northwest Region
* Somali Red Crescent
* Somaliland Medical Assoc
* Telesom

International Organizations and Governments:

Representatives from the following international organizations and government departments were also interviewed for this study.

In Nairobi:
* COOPI
* East Surrey Hospital
* European Commission
* Novib
* SACB Health Sector
* UNICEF
* UNDP
* WHO
* WSP International

In the United States:
* US Treasury
* US State Department
* USAID
* The World Bank
* The International Monetary Fund
* United Nations Development Program
* Office for the Coordination of Humanitarian Affairs
* National Security Council
* Harvard Business School
* Georgetown University
* Macalaster College (Minneapolis)

In London:
* Bannock Consulting
* DFID
* ICAR

In Copenhagen:
* Danish Institute for International Affairs
* Danish Foreign Ministry

In Geneva:
* ICRC
* IFRC
* IOM
* WFP
* WHO

NOTES

1 `Remittances: The New Development Mantra?' Devesh Kapur, Harvard University and Center for Global Development, August 25, 2003, Paper prepared for the G-24 Technical Group Meeting, p.5.
2 Feasibility Study on Financial Services in Somalia Final Report, KPMG, UNDP and EC, September 2003, p.4.

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Cerstin Sander, `Migrant Remittances to Developing Countries A Scoping Study: Overview and Introduction to Issues for Pro-Poor Financial Services', Prepared for the UK Department of International Development (DFId) by Bannock Consulting, June 2003.
Cerstin Sander & Samuel Munzele Maimbo, Migrant Labor Remittances in Africa: Reducing Obstacles to Developmental Contributions, Africa Region Working Paper Series No. 64, November 2003.
Friedrich Schneider & Dominik Enste, `Shadow Economies Around the World: Size, Causes, and Consequences', IMF Working Paper WP/00/26, February 2000.
Peter Temin & Hans-Joachim Voth, `The Speed of the Financial Revolution: Evidence from Hoare's Bank', Massachusetts Institute of Technology, Department of Economics Working Paper Series, March 2004.
Peter Temin & Hans-Joachim Voth, Banking As An Emerging Technology: Hoare's Bank 1702-1742', Massachusetts Institute of Technology, Department of Economics, Working Paper Series, December 2003.
UNDP Somalia, Financial Sector Development Project, Project Document, May 2004. UNDP Somalia, Socio-Economic Survey, 2002, Somalia, UNDP with the World Bank, Report No. 1, Somalia Watching Brief, 2003.
UNDP Somalia, Human Development Report for Somalia, Nairobi, 2002.
UNDP Somalia, Human Development Report: Somalia, 2001, UNDP, Nairobi.
John Wilson & Roger Ballard, `Informal Funds Transfer Systems: an analysis of Hawala', Department for International Development, Enterprise Development Department and Sustainable Livelihoods Support Office and Asia Regional Policy Department, Lunchtime Seminar, London, 10 January 2003.
Jan Wimaladharma, Douglas Pearce & David Stanton, `Remittances: The New Development Finance?' Small Enterprise Development Journal, March 2004.

NOTES

1 Zakat is the third pillar of Islam, and requires that 2.5 per cent of individual wealth should be redistributed annually for charitable causes.

2 This report has been prepared at the same time as efforts continue to establish a Transitional Federal Government (TFG) for Somalia, under the leadership of Mr Abdullahi Yusuf. No matter the success that might be achieved in this present effort, the creation of an effective government will take time, and will not result in a functioning health system - public or private - for a considerable time to come. Hence, the present research exercise might be useful to point to ways that an interim health system could be implemented or a system that could eventually fold into formal government-based medical authorities. Assuming that the TFG becomes functional, the new government will face some important choices over the future role of government (both federal and national) in social service provision - whether to assume a central role in the provision of services, or to allow the continuation of privatized service provision. A new government will not immediately have the resources to do anything other than provide regulation and policy development. Healthcare provision in practice, therefore, is likely to continue to be provided by a mixture of communities, international aid agencies, Islamic charities, diaspora organisations and Somali businesses. A new national ministry of health is likely to seek international support to become established. International donors should seek to avoid replicating the situation that existed pre-war, when the ministry of health was heavily reliant on foreign aid. As in other matters, the TGF will have to take into account that there is an established, if weak, health system in existence in Somaliland.

3 There are, however, a number of local and regional authorities operating in Somalia, some more successful than others. Perhaps the most successful example is Somaliland in the north-west, which declared independence in May 1991 and has since that time operated as an independent state, despite not having received recognition from any member of the United Nations. In Somaliland as well there is a Ministry of Health, while there are nominal ministries in Puntland in the north-east, and in Mogadishu, the capital of the Transitional National Government, which has been unable to extend its authority to cover even the city of Mogadishu since its establishment was announced in August 2000.

4 Although reference to failed states has become routine in recent years, this project instead endorses collapsed or imploded for four reasons. First, the term implies that there are standards of success to which all states aspire, which is not the case. The modern state is a `work in progress', so even if there were standards, they would be changing according to arbitrary rules. Second, no state has a complete monopoly on violence - to use Weber's definition of measuring effectiveness of government - and perhaps the variations can tell us about when and how a state will implode. Third, the term also suggests that if an unruly dictator had maintained control over the state, it would therefore not have failed. And fourth, it ignores the reality that many of these states, especially in Africa, were bound to encounter difficulties since Africa's illogical borders and state institutions were imposed by Europeans, without regard to ethnic groups, religion or physical territorial markers.

5 See http://www.un.org/depts/ocha/cap/somalia.html for more information. Accessed on 20 July 2004.

6 Estimates vary from 7 to 9 million. UNDP's Human Development Report for 2003 lists the population as 9.1 million. See http://www.undp.org/hdr2003/indicator/cty_f_SOM.html accessed on 6 September, and also for the full range of figures see http://www.reliefweb.int/w/bkg.nsf/vBS?OpenView&StartKey=Somalia:+Country+Profiles&ExpandView.

7 In particular, see Socio-Economic Survey, 2002, Somalia, UNDP with the World Bank, Report No. 1, Somalia Watching Brief, 2003.

8 See UNDP Human Development Report: Somalia, 2001, UNDP, Nairobi, p.195.

9 Council of the European Union, `Improving Access to Durable Solutions: Communication from the Commission to the Council and to the European Parliament on the managed entry in the EU of persons in need of international protection capacity of the regions of origins' [COM(2004) 410 Final, 7 June 2004.

10 See G8 Action Plan: Applying The Power Of Entrepreneurship to The Eradication Of Poverty, 2004 Summit, Georgia, United States, on http://www.g8usa.gov/home.html, accessed on 1 September 2004.

11 `The Development Dimensions of Migrant Transfers', Ninna Nyberg Sorensen, Danish Institute for International Studies, November 2003, p.1.

12 AMAP Newsletter, August 2004, 1:1, p.2. See also `Migrant Remittances to Developing Countries - A Scoping Study: Overview And Introduction to Issues For Pro-Poor Financial Services', Prepared For The UK Department of International Development (DFId) By Cerstin Sander, Bannock Consulting, June 2003, p.4.

13 `Migrant Remittances: Country of Origin Experiences - Strategies, Policies, Challenges, and Concerns', International Migration Policy Programme, at the DFID conference, 9-10 October 2003, p.4.

14 Foreign drug couriers who are arrested in the UK have reportedly sent money back home. According to The Economist, `Drug couriers tend to come from needy families - that is why they agree to carry mysterious packages into Britain - and if the breadwinner is in prison, the need must be met from there. So a steady stream of remittances flows from Wormwood Scrubs to poor countries. The same is true even of stingy establishments such as Holloway, a women's prison in London, where wages can be as low as �7 per week.' Economist, 8 May 2004, p.35.

15 Manuel Orozco, `The Remittance Marketplace: Prices, Policy and Financial Institutions', The Pew Hispanic Center Report, Washington, DC, June 2004, page 2.

16 This is one of the many terms used to describe the informal remittance companies.

17 Cerstin Sander and Samuel Munzele Maimbo, Migrant Labor Remittances in Africa: Reducing Obstacles to Developmental Contributions, Africa Region Working Paper Series No. 64, November 2003, p.22.

18 Cerstin Sander and Samuel Munzele Maimbo, Migrant Labor Remittances in Africa: Reducing Obstacles to Developmental Contributions, Africa Region Working Paper Series No. 64, November 2003, p.3.

19 Orozco, Pew, p.7.
20 Orozco, Pew, p.23.
21 Orozco, Pew, p.24.

22 `Mexican Hometown Associations And Development Opportunities', Manuel Orozco, with Michelle Lapointe, Journal of International Affairs, Spring 2004, vol. 57, no. 2, p.50.

23 `Remittances to Eritrea were 194 per cent of exports and 19 per cent of GDP in 1999. For Cape Verde the same values were 51 percet and 12 per cent; for Comoros, 24 precent and 6 per cent; for Egypt, 26 per cent and 4 per cent; and for Morocco, 18 per cent and 5 per cent (Rapoport and others 2001).' Cerstin Sander and Samuel Munzele Maimbo, Migrant Labor Remittances in Africa: Reducing Obstacles to Developmental Contributions, Africa Region Working Paper Series No. 64, November 2003, p.15.

24 The figures are taken from Manuel Orozco, `Worker Remittances in an International Scope', paper commissioned by the Multilateral Investment Fund of the Inter-American Development Bank, Inter-American Dialogue, Research Series: Remittances Project, March 2003, p.3. According to Manuel Orozco, `In 2002, for example, remittances accounted for nearly 30 per cent of Nicaragua's GDP and 25 per cent of Haiti's. In Honduras, Nicaragua, El Salvador, and a few other of Latin America's poorest nations, remittances may be more than doubling the incomes of the poorest 20 per cent of the population.' `Mexican Hometown Associations And Development Opportunities', Manuel Orozco, with Michelle Lapointe, Journal of International Affairs, Spring 2004, vol. 57, no. 2, p.51.

25 Cerstin Sander and Samuel Munzele Maimbo, Migrant Labor Remittances in Africa: Reducing Obstacles to Developmental Contributions, Africa Region Working Paper Series No. 64, November 2003, p.1.

26 `Remittances: The New Development Mantra?' Devesh Kapur, Harvard University and Center for Global Development, August 25, 2003, Paper prepared for the G-24 Technical Group Meeting, p.5.

27 From correspondence with Cerstin Saunders, 28 September 2004.

28 Interview Dr Manuel Orozco, Washington, DC, 21 June 2004.

29 See `Remittances at USAID', on

http://www.usaid.gov/our_work/global_partnerships/gda/RemittancesatUSAID.doc, 8/26/04, accessed on 9 September 2004 for USAID's policies and activities with respect to remittances.

30 For further information, see `The Development Dimensions of Migrant Transfers', Ninna Nyberg Sorensen, Danish Institute for International Studies, November 2003, p.21; see also Remittances: The New Development Mantra?' Devesh Kapur, Harvard University and Center for Global Development, August 25, 2003, Paper prepared for the G-24 Technical Group Meeting, p.27.

31 For more information, see Mexican Hometown Associations And Development Opportunities', Manuel Orozco, with Michelle Lapointe, Journal of International Affairs, Spring 2004, vol. 57, no. 2.

32 See Nyberg Sorensen, `The Development Dimensions of Migrant Transfers', p.9, for more information.

33 For more information on Morocco, see Nyberg Sorensen, `The Development Dimensions of Migrant Transfers', p.24; and for Mali, see Sander and Munzele Maimbo, Migrant Labor Remittances in Africa, p.29.

34 `The Kayes region of Mali, home to the great majority of migrants to France, has benefited from support by some 40 immigrant associations in France, most of which have counterparts in Kayes. In the span of a decade, these associations supported 146 projects with a total budget of about three million euros, of which some 94 per cent came from immigrant savings and the rest from donor-funded NGOs.. The success of the individual projects has depended largely on the level of involvement of local villagers. Where expatriates covered the full cost, villagers took least interest and were difficult to engage. Nigerian migrants reportedly make individual or pooled remittances through `home improvement unions' , Sander and Munzele Maimbo, Migrant Labor Remittances in Africa, p.18. See also Ralph Grillo & Bru no Riccio, `Translocal Development: Italy-Senegal', International Workshop on Migration and Poverty in West Africa, University of Sussex (8186), March 2003.

35 Comments on the Ghana health care scheme funded by the Ghanaian diaspora, by Prof Richard Black at House of Commons Select Committee on International Development, 6th Jan 2004, on Migration and Development, Minutes of Evidence.

36 Dahabshiil Company Profile, p.2.

37 `Unconventional Somali Economy', p.213.

38 See Cindy Horst, `Vital links in Social security: Somali Refugees in the Dadaab camps, Kenya', in `Displacement in Africa: Refuge, Relief & Return', UNHCR Refugee Survey Quarterly, 21:1 & 2, Oxford University Press, Oxford, 2002.

39 Feasibility Study on Financial Services in Somalia Final Report, KPMG, UNDP & EC, September 2003, p.4.

40 Feasibility Study, p.8.

41 Comments to the International Development Committee by Dr Shire, Dahabshiil, 9 March 2004.

42 `Regulation and supervision in a vacuum: the story of the Somali remittance sector', Abdusalam Omer and Gina El Koury, March 2004 Small Enterprise Development Vol.15 No.1, p.47.

43 For more information, see Peter Hansen, `Migrant transfers as a development tool: The case of Somaliland', DIIS, Migration-Development Workshop III, Copenhagen, March 9, 2004. v 44 See Ismail Ahmed, `Remittances and their Economic Impact in Post-war Somaliland' Disasters, 2000, 24 (4), pp 380-389.

45 See Ahmed, `Remittances and their Economic Impact in Post-war Somaliland' pp 380-389.

46 See Peter Hansen (2003) Revolving Returnees: Return Migration in Somaliland. Danish Institute for International Studies Copenhagen. Paper presented at the workshop: `Determinants of Transnational Engagement'. Diis, Copenhagen and FLACSO, The Dominican Republic. Santo Domingo, November 27 - 29, 2003; Lee Cassenelli (2004) `The Role of Diaspora Communities in Homeland Development' in R. Ford, Hussein Adam, Edna Aden (eds) War Destroys, Peace Nurtures: Somali Reconciliation and Development. Red Sea Press.

47 See Cassanelli (ibid) for these definitions.

48 `A steering committee in London that combined Somali expertise and leadership with British know-how and experience worked in close collaboration with an interim council in Somaliland. Local businesses in Somaliland took full responsibility for rehabilitating the government-donated dilapidated old-school building that was in fact home to over 500 returned Somali refugees. Somalis in Sweden provided 750 chairs and tables; Kuwait-based Somalis sent computers. In the project's second year, the Somaliland Forum, a cyberspace-based global network of Somalis formed taskforces to tackle specific elements, raised money, maintained email groups, and hosted real-time e-conferences. The steering committee in London consulted back and forth with the interim council in Somaliland - made up of elders, government ministers in formal and personal capacities, local business people, and local mayors - to identify the priority academic areas to receive immediate attention based on local needs. The steering committee drew on its expertise to write a curriculum for these academic areas, a charter for the university and the business plan. `Diaspora and development: University of Hargeisa, Somaliland case study', Afford (web site).

49 A number of Somalilanders in the diaspora, who wish to return to Somaliland to live, have been involved in development projects with the aim of improving public infrastructure in the region, particularly roads, schools and medical clinics, so that they can bring their families home. One such group, called Somscan, started as a group of Somalilanders in Scandinavia, but soon expanded to include groups in the United Kingdom as well, and the name changed to Somscan and UK Cooperative Associations. According to Kleist, `Today there are eight pieces of land (almost) next to each other, which have all been bought for prices between $17,000 and $20,000. The Somscan area has now expanded to be about 100 hectares. Each Somscan member has paid $1,000, which covers the acquisition of land as well as other costs. Altogether 330 families are presently members of Somscan and the project is closed for new members. About 15 families are said to have returned to Somaliland and have settled in Hargeisa, Burao or other Somalilandic towns and/or have invested in land in different areas. In summer 2003, Somscan received a EU grant to establish water supply and renovate a primary and secondary school close to the planned Somscan residential area.' Nauja Kleist, `Somali-Scandinavian Dreaming: Visions of home and return in Somscan and UK Cooperative Associations', Paper presented at Sussex Centre for Migration Research Seminar, University of Sussex, February 26, 2004, pp.4-5.

50 In Somalia, two levels of concerted group action stand out. These are the dia (blood compensation) paying group, and the clan. The former employs the pervasive Somali concept of political contract (heer/xeer) to tie down and bind together in common legal cause (as an insurance group) close kin within the clan (and in the case of small clans, the whole clan). The individual members of a dia-paying group pay and receive damages in concert for death or injuries sustained, or inflicted, by a member of the group. In Somali customary law (heer/xeer) these are treated as wrongs (or torts) requiring reparation, rather than as crimes implying punishment. (Menu of Options, p.2)

51 Interview with a Somali holding a Dutch passport in Hargeisa, who had recently returned to Somaliland from the UK.

52 UNDP Human Development Report for Somalia 2001.

53 UNDP Human Development Report for Somalia 2001

54 This was $60 million in 2003, though distorted by the GFATM funding. See Somalia Aid Coordination Body Donor Report, 2003.

55 The efficacy of cost recovery in health service provision, popularised in the1990s by the Bamako Initiative, is increasingly questioned by health agencies.

56 They may also provide some physical protection, as doctors have been targeted in the past for assassination and kidnapping.

57 It is worth noting that a significant portion of programme implementation is dependent upon the Somali staff of agencies, or Somalis contracted to participate in individual campaigns.

58 In urban areas there are a growing number of examples where private private companies have taken over the management of water supplies, with some local authority oversight. v 59 Burns notes that `many of the aid programmes being provided in Somalia are vertical programmes, such as for example tuberculosis, malaria, HIV/AIDS, nutrition, immunisation and vaccination .[where].the programmes are not integrated and this causes serious overlaps. There are reported overlaps and gaps in terms of coverage of population groups and georgraphical areas by different organizations sometimes undertaking very similar, if not identical programmes..The absence of integration at international organization level contributes to an already chaotic situation..' Monica M. Burns, `Identification of Capacity Building Interventions for Local Health Authorities in Somalia: Final Report' [Framework Contract AMS 451, LOT #8, European Commission], February 2004, pp.18-19.

60 Monica M. Burns, `Identification of Capacity Building Interventions for Local Health Authorities in Somalia: Final Report' [Framework Contract AMS 451, LOT #8, European Commission], February 2004, p.21 61 Organizations such as the International Committee of the Red Cross directly run hospitals, for example, in Mogadishu.

62 World Bank, Country re-engagement Note: UNDP/World Bank - Somalia, February 2003, p.11

63 UNDP/World Bank LICUS programme for 2004

64 Monica M. Burns, `Identification of Capacity Building Interventions for Local Health Authorities in Somalia: Final Report' [Framework Contract AMS 451, LOT #8, European Commission], February 2004, p.28

65 According to the SACB, expenditure for `health and nutrition' in Somalia for the year 2003 was $60,484,224. This figure, according to the SACB, does not include $26,791,633 for inter alia water and sanitation as well as infrastructure.

66 Burns, op cit, p.18.

67 This section was informed by the field work of Andre LeSage, and in particular, `The Rise of Islamic Charities in Somalia: An Assessment of Impact and Agendas - Final Draft', Presented to the 45th Annual International Studies Association Convention, Montreal, 17 - 20 March 2004.

68 There are `structural' barriers to coordination, including the fact that most Islamic charities are based in Mogadishu, while the SACB is in Nairobi. Moreover, NOVIB and the SACB Education Sectoral Committee are making strong efforts to increase collaboration with the Islamic charities. According to LeSage, in 2002, `Egypt did acknowledge allocating a sum of $1 million. Yet, when the SACB applied to the Egyptian embassy to Kenya for information for the 2003 report, its staff was told not only that no information be would be provided for 2003, but also that the figures for 2002 were totally inaccurate.'

70 The best-known are the Kuwaiti-based Africa Muslims Agency, the UAE-based Red Crescent Society, the Saudi-based World Association of Muslim Youth, the Al Islah Charity, the Saudi-based Muslim World League / International Islamic Relief Organization, the Sudan-based Dawa al Islamiyya; and the Al Wafa Charitable Society, which is listed as a Specially Designated Terrorist Entity by the US government.

71 LeSage, The Rise of Islamic Charities in Somalia: An Assessment of Impact and Agendas - Final Draft', Presented to the 45th Annual International Studies Association Convention, Montreal, 17 - 20 March 2004, p.13. 72 Burns, February 2004.

71 Instead, local offices of the charities raised additional funds within the communities.

73 One panel member noted that Somali medical staff have also been victims.

74 Somalis in the United States and in the United Kingdom in particular frequently emphasised the fact that they had two or three jobs, and that this work load was essential not only to survive but also to ensure the regular transmission of remittances to their families. At the same time, some accepted that the burden of remittances could be extremely difficult to bear, that they did not know how long they could sustain the commitment and that remittances were becoming more `periodic' than regular. Impressionistically, 15-20 per cent of respondents talked in such terms.

75 From Amal Group Profile - Sky is the Limit, 2004.

76 It is worth noting here that this type of health insurance differs from typical western insurance, which normally has a very high overheads, often up to 25 per cent or more of costs, and which therefore is considered a poor way to sustain health care in these places.

77 A system whereby approximately 40 women contribute small amounts to a common pool, which is then shared out on a monthly basis between two or three women at a time, so that they can use the funds to develop an enterprise or pay off debts.

78 Dr. Ahmed Esa from IPRT [Hargeisa] informed the interviewers by e-mail on 23 August 2004 that `we have been debating on ways to link the relatively large remittance infloiw and development projects for some time..We have no convinced Dahabshiil to start its own profit foundation [the same way Western Union has]. Dahabshiil will donate to this foundation the amount of money it now already gives out on charity. Our idea is then to link this to donations from the diaspora and other assistance programs. For example, a local group in Somalia may apply to Dahabshiil for funds to build a hospital. Dahabshiil may give a certain amount and ask diaspora communities to help that specific project, for example, by adding 1 per cent to the commissions they pay on sending remittances. This would be voluntary.'

79 Findings discussed at the 6 September 2000 Workshop on Risk, Poverty and Insurance: Innovations for the informal economy emphasised the importance of insurance for the informal sector because 60 per cent of employment in Latin America, Africa and Asia is in the informal sector, the major source of new jobs. `However, information on insurance and micro-insurance is still, to a large extent, lacking, with the need for more and better monitoring and evaluation, and information on access by the poor..'

80 UNICEF is planning an assessment to examine utilization of health services in Somalia. In addition, it would be useful to look more closely at financing issues.

81 In the late 1990s there were attempts to apply a cost-sharing policy in order to find a sustainable way of financing services. One can assume that in some families remittances are used to pay user fees. Most agencies are trying to implement this policy, though many are questioning its effectiveness. The SRCS and the Federation have a study that is more positive. These points emphasize the need for undertaking a study as proposed here.

82 Human Development Report for Somalia, UNDP, Nairobi, 2002

83 Estimates of the Somali population in Somalia, itself, normally are around 6.5 million, while estimates of Somalis living outside Somalia are around 1 million, or, approximately 16 per cent of all Somalis.

84 Remittances are also affected by economic conditions in host nations, and, hence, the estimate of $700 million is made even more uncertain due to the economic fluctuation factor. The 2001-2002 restrictions imposed by various Western governments on informal remittance houses, such as Al Barakat, led to a significant, though seemingly temporary, dip in remittances. However, one can probably conclude with a significant degree of confidence that - despite such fluctuations - the flow of remittances will probably continue to be a very strong social support mechanism for indigenous Somalis for at least another two decades, ie, the working lifespan of first generation Diaspora.

85 The remarks about Diaspora attitudes are impressionistic, based principally upon discussions that the author had with members of the Diaspora in London, Copenhagen, Washington and Nairobi.

86 Xawaalaad refers to the money transfer or remittance system through which resources flow into Somalia via the Diaspora. The development of the xawaalaad system has been regarded as essential for not only social support, but also for the expansion of commerce over the past six years. The informal nature of the xawaalaad system led to concerns following the attack on the World Trade Towers on 11 September 2001 that this system might also serve to transfer funds for terrorist activities.

87 Both formal and academic research undertaken in Europe and the United States notes the high proportion of Diaspora that continue their clanic linkages and rivalries even in their host countries where circumstances ostensibly are different.

88 Narbeth, Simon, The Targeting of Emergency Food Distribution in Somalia: Vulnerability, Redistribution and Beneficiary Participation, World Food Programme, 2001.