Chaos and violence prompted MSF to pull out of Somalia. With no signs of improvement, and a weak health infrastructure, what next for the country? Talha Khan Burki reports.

On Aug 14, Médecins Sans Frontières (MSF) announced that it would be withdrawing from Somalia. Since the country descended into chaos in the early 1990s after the overthrow of President Siad Barre, 16 MSF workers have been killed in Somalia and there have been numerous attacks on the agency's medical facilities and ambulances. But the decision to close all its programmes in the country became inevitable only after MSF had concluded that armed groups and community leaders were complicit in targeting the agency.

“The same actors with whom MSF must negotiate minimum guarantees to respect its humanitarian mission have played a role in the abuses against MSF staff, either through direct involvement or tacit approval”, the agency stated.

Earlier this year, two Spanish members of MSF staff were released from captivity after being kidnapped from Kenya's sprawling Dadaab refugee camp and held in Somalia for 21 months. “Nobody has stood up to say that it is unacceptable to threaten, abduct, or kill doctors, nurses, or other staff”, commented MSF's president Unni Karunakara.

The agency emphasised that culpability lay with all parties in Somalia. “Acceptance of violence has permeated Somali society and this acceptance is now shared by many armed groups and many levels of civilian government, from clan elders to district commissioners to the Federal Government of Somalia”, said Karunakara.

As a consequence, the agency felt it had no option but to withdraw from the entire country, and it is unlikely to return any time soon. Somalia is split into three regions: Somaliland in the northwest, a relatively stable state that declared independence in 1991; the semi-autonomous state of Puntland in the northeast, where roughly a third of the population lives; and the anarchic south and central regions of the country. MSF's departure means that 1–1·5 million Somalis will be without access to health care. Last year, they were responsible for over 600 000 medical consultations and provided care for more than 30 000 malnourished children as well as some 60 000 vaccinations.

MSF offered a range of services that will be almost impossible for any single partner to replicate: free primary health care, emergency services, malnutrition treatment, maternal care, surgery, tuberculosis treatment (it was the sole provider of therapy for multidrug-resistant tuberculosis, and has made provisions for these patients to complete their treatment), and water and relief supplies. In Somaliland, the agency offered support to a psychiatric unit—the strife of the past two decades has left an enormous burden of post-traumatic stress disorder, depression, and anxiety. Somalia is vulnerable to epidemics of malaria, leishmaniasis, and cholera, and is in the midst of measles and polio outbreaks—MSF's outbreak response efforts will be sorely missed.

In parts of south and central Somalia, MSF was often the sole provider of health care. “There are areas where we are quite sure that there is no other actor who can take over from us”, Marit de Wit, a doctor and health adviser at MSF, Amsterdam, Netherlands, tells The Lancet. Much of the region remains under the control of al-Shabaab, an al-Qaeda affiliate that has a history of hostility towards humanitarian organisations. Al-Shabaab were responsible for bombing a Nairobi shopping mall last month. “It will be very difficult to get partners to work in the areas that are not under government control”, conceded de Wit.

In 2011, in the middle of a famine that killed an estimated 260 000 Somalis and drove tens of thousands from their homes, al-Shabaab banned 16 aid agencies, including several UN bodies, from operating in areas under their aegis. Opposition to outreach immunisation services meant that 1 million Somali children could not access measles and polio campaigns, the consequences of which are made manifest by the current outbreaks. Polio had been absent from Somalia since 2007. It is now spreading quickly; according to UNICEF, Somalia contains “the largest known reservoir of unvaccinated children in a geographic area in the world” (around half a million children).

In Marera, southern Somalia, MSF had supported a hospital treating roughly 4000 patients a month. They provided inpatient admissions for malaria patients, nutrition treatment for 600 children, and facilities for women to give birth by caesarean section. “We don't know what will happen to these people”, says de Wit.

MSF president Unni Karunakara announces the agency's withdrawal from Somalia Copyright © 2013 Thomas Mukoya/Reuters/Corbis

Anirban Chatterjee, head of the Health Programme at UNICEF Somalia, based in Nairobi, Kenya, admits that MSF's exit is a major setback. “Certainly there will be an immediate vacuum, because MSF have already left, but the other development partners and non-governmental organisations are stepping in”, he tells The Lancet. “In the larger facilities, the services might actually be taken over by multiple partners, so that process might take longer, but as you go down to the lower levels of health care, a small or medium sized partner might be able to take over what MSF was doing.” So far, 13 agencies have been identified to run 14 of the 20 health facilities left by MSF, but lack of funding remains a huge challenge—an estimated US$16·6 million will be needed to finance the nutritional and health-care activities previously undertaken by MSF.

Aside from DR Congo, Somalia is the worst country in the world to be a mother—74% of pregnant women go without any medical care, the highest proportion in the world, and maternal mortality is steep. In no other country do more infants die within 24 hours of birth, and the under-five mortality is an appalling 180 per 1000 livebirths. None of the vaccination campaigns can boast coverage of over 50%.

At the beginning of the year, more than 2 million Somalis were food insecure. Rates of severely acute malnutrition are high, especially in the south. There are an estimated 1·3 million internally displaced Somalis—roughly 370 000 in Mogadishu alone—and around the same number have fled to neighbouring countries. It adds up to a third of the Somali population and whether within or without the country, these people have a particularly precarious existence. Last year, the Dadaab camp, where MSF will continue to work, saw 11 disease outbreaks; cholera and hepatitis E are ongoing problems.

Yet recent events had prompted much hope. The first parliament to sit in the country since 1991 was inaugurated last year. The new government was widely credited with heralding a new era for Somalia. Foreign aid flooded in. Ex-pats have started to return. Mogadishu, which was recovered from al-Shabaab in 2011, has seen a construction boom and the port is up-and-running again. Piracy is no longer the grave concern of a few years ago and thanks to the efforts of African Union and Kenyan forces, al-Shabaab have been driven out of all their urban strongholds.

Meanwhile, the pentavalent vaccine was introduced to Somalia. The GAVI board gave exceptional approval for support to Somalia despite its routine immunisation coverage being far below the 80% usually required. “The decision was based on the disease burden and the huge need”, explains Anne Cronin, senior country support manager for Somalia at GAVI Alliance, Geneva, Switzerland. The vaccine was launched in April, 2013, in all three zones in the country, and Cronin recalls a prevailing spirit of optimism. “The British were reopening their embassy and the UN agencies were planning to re-establish their offices.”

Since then, there has been a marked deterioration in security. In June, an attack on the UN compound in Mogadishu killed 15 people, bomb attacks in early September killed around 20 people in the city, and there was an unsuccessful attempt to assassinate President Hassan Sheikh Mohamud. Al-Shabaab claimed responsibility for all three attacks.

Some experts wonder whether the vaunted turnaround in Somalia's fortunes is any such thing. The government is entirely dependent on foreign forces, and its writ barely extends out of Mogadishu. There are murmurings of a rift between the Hawiye and Darood clans; if this explodes into violence the consequences would be catastrophic. And of course al-Shabaab, excluded from the negotiating table, remains a potent threat. MSF's exit from Somalia might not presage similar moves from other organisations: it operates in a manner untypical of aid agencies; it is well resourced, recruits its staff directly, and offers ongoing interventions. In Somalia, this attracts attention. Other agencies might be able to keep a lower profile. But the withdrawal certainly indicates that those on the front line may not share the optimism over Somalia's future.

Chatterjee counters that much of Somalia is not out of reach. “The issue of low immunisation is a function of multiple factors—not just accessibility.” Hargeisa, Somaliland's capital, plays host to GAVI's logistics centre. WHO is even undertaking surveys in the state, and obtaining baseline data (although Hargeisa has come under attack from al-Shabaab in the past, and the militants recently reiterated threats against westerners in the city).

As long as the centre holds, Chatterjee believes that progress can be made over the next few years. “If the government can plan over 3 years, we can establish sustainable systems.” He believes that current investments in health care will pay dividends over a 5-year period, at which time it is conceivable that some of Somalia's woeful health indicators will start to improve. Nonetheless, prospects for large parts of the country remain bleak. “There is a polio outbreak, measles everywhere, malaria, and many children who were on our feeding programmes are now without support”, notes de Wit. “A disaster for Somalia is not a future scenario, it is happening already.”

interview with the author about the effect of MSF's withdrawal from Somalia listen to The Lancet News podcast, Sept 27 episode For anlisten to The Lancet News podcast, Sept 27 episode http://www.thelancet.com/lancet-news-audio/