Background

The first case of the Novel Coronavirus (SARS Cov-2) in Somalia was confirmed on the 16th of March 2020¹ , five days after the World Health Organization (WHO) declared the disease “a global pandemic”. As of 16 June 2021, Somalia reported 14,841 confirmed cases and 775 deaths². The first wave of the infection lasted almost four months between mid-March 2020 and July 2020, with a weekly average of 173 confirmed cases and 5 deaths. The infection rate has risen sharply in the second wave between February 2021 and May 2021, with a weekly average of 553 confirmed cases and 36 deaths, an ominous signifier of more rapid spread of the infection and the loss of more lives than the previous wave in 2020².

On the 15^th March 2021, Somalia become one of the first 12 African countries to receive COVID-19 vaccine supply through the COVID-19 Vaccine Global Access (COVAX) Facility³. COVAX initiative is supported by WHO, GAVI, and the Coalition for Epidemic Preparedness Innovations (CEPI) to improve equitable access and distribution of COVID-19 vaccines around the world. It procures a supply of COVID-19 vaccines for low- and middle-income countries under the pooled procurement mechanism

¹Somalia confirms first case of coronavirus – health minister. Available at https://www.reuters.com/article/health-coronavirus- somalia-idUSL8N2B92GA

² WHO EMRO, Somalia COVID-19 data summary dashboard. Available at https://covid19.who.int/region/emro/country/so; as of Sunday 23 May 2021, at 21:00 GMT

equivalent to inoculate twenty percent (20%) of their population. UNICEF, WHO, GAVI and other partners worked together to develop guidance, tools and training resources to support countries in assessing their readiness and planning to introduce and roll out COVID-19 vaccination.

Somalia received 300,000 doses of Oxford/AstraZeneca COVID-19 vaccine to inoculate at risk groups i.e., pre-existing social and medical vulnerabilities such as frontline health workers –older adults and people with underlying clinical conditions. It also received additional 200,000 Sinopharm⁴ and 2,000 Sputnik vaccine doses donated by China and the United Arab Emirates respectively. The vaccination programme for COVID-19 was launched on 16th March 2021 amid national election impasse which eclipsed this important occasion to mark the start of the COVID-19 vaccination campaign in Somalia. Since then, the rollout has faced a daunting list of challenges most importantly operational and logistical constraints due to limited funding, and vaccine hesitancy in the wake of the news about rare side effects from Oxford/AstraZeneca vaccine. Hence, This study on the status of COVID-19 vaccine rollout in Somalia, assesses the existing

³ COVID-19 Vaccine arrive in Somalia. Available at https://www.unicef.org/somalia/stories/covid-19- vaccines-arrive-somalia

⁴ Somalia Receives China-donated Sinopharm Vaccines. Available at http://www.xinhuanet.com/english/africa/2021- 04/12/c_139873472.htm

opportunities and challenges to the COVID-19 mass vaccination and proposes policy options and recommendations to address the identified rollout gaps for COVID-19 immunization.

Methodology

A rapid desk review of the available literature on COVID-19 vaccination rollout in Somalia and countries with similar context was conducted first; available secondary data of the COVAX vaccine rollout in Somalia was collected through stakeholder’s consultation and primarily from the Interactive Somalia COVAX Monitoring Delivery Dashboard⁵. To draw diverse perspectives and provide further understanding and insight into the COVID-19 vaccination data, unstructured interview guide was used to collect the primary data from 22 Key Informant Interviews (KII) of senior officials from the Federal and Federal Member State MoHs, public health practitioners, WHO staff, academics, vaccinators, religious and traditional leaders and members of the general public between April and May 2021.

Somalia COVID-19 Vaccine Deployment Plan

In December 2020, the Federal Ministry of Health with the support of WHO and UNICEF developed COVID-19 Vaccine Deployment Plan which set out strategies

and activities to deliver COVID-19 vaccination programme in the country. To meet the conditions for COVAX assistance, a new regulatory agency for medicines and vaccines designated as the National Regulatory Authority (NRA) was created to provide the necessary assessment and authorization for the delivery of the new COVID-19 vaccines to ensure standards of safety and effectiveness.

Collaboration between the Federal MoH and FMS MoH has been a key part of the approach to realize a nation-wide vaccination programme. A steering committee, The National Vaccine Coordination Committee for COVID-19 comprising of the Director Generals of the MoHs at the Federal and FMS levels was formed to coordinate, implement and oversee the rollout.

COVAX supplied 300,000 doses of Oxford/AstraZeneca vaccines to Somalia which were distributed to the Federal Member States, Banadir region and “Somaliland”. A ten days vaccination campaign was launched to offer the first vaccine dose to priority groups identified in the deployment plan. The vaccination programme delivery model was designed around utilizing a network of existing public health facilities and few private hospitals mainly in urban centers with the adequate capacity and experience to provide vaccination services.

⁵ SOMALIA COVAX Delivery Monitoring Dashboard. https://app.powerbi.com/view?r=eyJrIjoiZThhNzFmM zMtODZlNS00YzhlLTg2MTktOTNiOTFiNjUxYzU2IiwidCI

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FmYjU5MCIsImMiOjh9&pageName=ReportSection

A mobile telephone based electronic registration system, CommCare, was introduced to record patient details and also used for vaccine safety surveillance,

i.e. monitoring of adverse events, and to communicate with vaccine recipients by sending SMS to remind them of their second doses.

Status of COVID-19 Vaccine Rollout in Somalia

As of 16 June 2021, more than 160,759 (54%) people was inoculated with COVID-

19 vaccine, while 137,157 (45.7%) individuals received their first dose. Banaadir region which was allocated the

highest vaccine doses (85,000 doses) administered only a quarter of the planned vaccinations while Somaliland which was given the second largest share (65,000 doses) successfully administered 87.8% of the vaccines received. Table 1 below summarizes COVID-19 vaccination by States in Somalia.

The uptake of the second dose has been very slow as only 23,602 (17%) people have so far received their second dose. Puntland performed remarkably well in the second dose COVID-19 vaccination administering 12,611 (83%) individuals for second dose.

Table 1: COVID-19 vaccine rollout (up to June 16,2021)

(88)

Source: WHO/Federal MoH. AZ – AsteraZenaca, SN – Sinopharm

The KI interviews indicated that confidence barriers which relate to concerns about the safety and effectiveness of Oxford/AstraZeneca could be one of the main factors for the low uptake of COVID-19 vaccine in Somalia. The arrival of COVID-19 vaccine

coincided with the reports of rare cases of blood clotting in people who received Oxford/AstraZeneca vaccine and the subsequent suspension and limitation of its use in certain age groups in a number of European countries in March 2021. The low COVID-19 vaccine uptake seen in April

and May 2021 was attributed to specific concerns about the permissibility of the vaccination during fasting religious observance in Ramadan.

The slow pace of the vaccination programme in most of the Federal Member States and Banaadir region is in contrast with Somaliland where the relatively  good  uptake  of  COVID-19

vaccine was ascribed to better community mobilization, awareness and outreach services.

Regarding the priority groups, front line workers represented the highest vaccinated (44%) individuals followed by elderly population (34%) and healthcare workers (22%). See table 2.

Table 2: COVID-19 vaccine uptake priority groups (up to June 16,2021)

Banadir 24,278 6,243 (26%) 10,085 (42%) 7,950 (33%)

Jubaland 7,486 1,447 (19%) 4,163 (56%) 1,876 (25%)

Hirshabele 11,278 3,275 (29%) 6,803 (60%) 1,200 (11%)

Somaliland 57,090 12,695 (22%) 2,0621 (35%) 23,774(42%)

Source: WHO/FMoH, data represented only first dose.

Figure 1 Vaccinated people by Occupation. Source: Federal MoH / WHO Somalia (Does not include data from Somaliland)

The official COVID-19 data summary revealed significant disparity in vaccine access in Somalia. Significant majority of

the vaccinated people were male (69.1%) from urban settlements (92.5%), see figure 2. The data indicated that the majority of the four of the target priority groups (teachers, police, municipal officers and point entry staff) are men, which might explain the high number of vaccinated men compared to women but the data analysis also suggests that the limited social mobility of women, unequal access to information, low health literacy among women, and the perception of the risk of contracting COVID-19 infection, among other social and cultural factors, contribute to this gender disparity of COVID-19 vaccine uptake in Somalia. See figure 1.

Figure 2: Vaccinated people by settlements. Source: Federal MoH / WHO Somalia (Does not include data from Somaliland)

There is also a significant inequality in access to vaccines across different settings and settlements in the vaccinated population. People living in nomadic settlements and IDP camps and refugees were the least vaccinated people  (0.6%),  (0.7%)  and  (0.1%)

respectively, see figure 2. The distribution of vaccine supplies to fixed health centers in and around major towns and the lack of mobile and outreach vaccination teams are the main reason given for this low vaccine coverage of rural areas and IDP camps.

The major source of COVID-19 vaccine information was social mobilizers (42.8%) followed by radio (14.6%) and healthcare workers (14.1%), see figure 3. However, there are underutilization of valuable and

trusted sources of information such as religious leaders / mosques (0.2%), posters and leaflets (0.1%), and community meetings (1.8%) and peer engagement (1.4%).

Figure 3 Vaccination Promotion Campaign by Source of Information. Source: Federal MoH / WHO Somalia (Does not include data from Somaliland)

If the current very low rate of vaccination (0.8% of the population in 15 weeks) is not addressed, it could take Somalia many years to vaccinate 70-80% of its population. The pace of vaccination is likely to pick up some speed once more shipments arrive but the other contributing factors to the slow vaccine

uptake must be addressed. The longer it takes to vaccinate a significant proportion of the population, the greater the cumulative effect of more infections and deaths from COVID-19 with devastating consequences on people, the fragile health system and the economy of Somalia.

⁶ Ahmed, M.A.M.; Colebunders, R.; Gele, A.A.; Farah, A.A.; Osman, S.; Guled, I.A.; Abdullahi, A.A.M.; Hussein, A.M.; Ali, A.M.; Siewe Fodjo, J.N. COVID-19 Vaccine Acceptability and Adherence to Preventive Measures in Somalia: Results of an Online Survey. Vaccines 2021, 9, 543. https:// doi.org/10.3390/vaccines9060543

Figure 4 The continuum of vaccine hesitancy between full acceptance and outright refusal of all Covid-19 vaccines: adapted from Noni E. MacDonald, Vaccine hesitancy: Definition, scope and determinants, Vaccine, Volume 33, Issue 34, 14 August 2015

Challenges

COVID-19 vaccine rollout in Somalia represents the country’s largest-ever vaccination drive and as in many countries in fragile contexts, the government faces operational and logistic challenges despite the limited doses of vaccine received. Besides the need to build up a stable and sufficient

COVID-19 vaccine doses to immunize substantial proportion of the population to achieve herd immunity, the country also must secure funds to cover the operational cost of the rollout. The list of challenges to effective COVID-19 rollout is dauntingly long, but the main obstacles, summarized below, could be

⁷ Report of the SAGE Working Group on Vaccine Hesitancy, WHO, October 2014

⁸ The Guide to Tailoring Immunization Programmes (TIP), Increasing coverage of infant and child vaccination in the WHO European Region, WHO Regional Officer for Europe., 2013

⁹ Noni E. MacDonald, Vaccine hesitancy: Definition, scope and determinants, Vaccine, Volume 33, Issue 34, 2015, Pages 4161-4164, https://doi.org/10.1016/j.vaccine.2015.04.036.

overcome with better planning, innovation and collaboration between all stakeholders.

Limited Vaccine Supply: Somalia was poised to receive around 6.2 million vaccine doses from COVAX facility to immunize 20% of its population. It has so far received 300,000 doses of COVID-19 Oxford/Astra Zeneca vaccine in mid- March 2021 and was expecting to receive a second shipment of 300,000 to be used as a second dose in April 2021. The export suspension on Oxford / Astra Zeneca vaccine by India has delayed the second shipment and forced Somalia health authorities to revise the country’s vaccine deployment plans and settle for using the remaining COVID-19 supplies for second dose only.

Limited Funds for Operational Costs: The second biggest challenge to COVID- 19 vaccine rollout in Somalia arose from lack of adequate funding for operational costs, which significantly affected not only the accessibility of the vaccines but, by and large, the ability of the health authorities to implement the vaccine deployment plans. The Federal MoH approached World Bank for assistance to cover the operational costs in December 2020 but once the vaccines were delivered through COVAX facility, no financial assistance was forthcoming from the World Bank and there were no financial contingency plans in place to fill the funding gaps. UNICEF and WHO stepped in to cover the operational costs of the first phase of vaccination rollout in Somalia.

Poor Health Infrastructure: It is a formidable operational and logistic challenge to Somalia’s weak health system to deliver a large-scale vaccination programme, which requires a well-functioning logistics system, sufficient supplies and trained medical personnel, among others. The use of the

meagre resources of the health system for COVID-19 vaccination programme would stretch the essential health services, jeopardize the routine immunization programmes and pose serious long-term consequences for the health and economic development of Somalia.

Restricted Access to Vaccines: The current model – urban-based, fixed health center vaccination sites – has restricted the access to vaccines for vulnerable communities including people living in rural and hard to reach areas, Internally Displaced People (IDPs) and refugees. The prioritization of frontline health care workers, teachers, municipal officers, police and point of entry workers for vaccination excluded these marginalized and vulnerable communities from the opportunity to be vaccinated in the first phase as very few of them could meet these criteria. The vaccination data indicate that 72% of vaccinated people fell into these five categories.

Transport and Security Challenges: In the Federal Member States of Jubbaland and South West, a number of towns and villages are accessible only by air due to insecurity and poor transport infrastructure, complicating the existing distribution challenges and hampering the vaccine rollout. These States also contain big districts with sparse health facilities, which presents serious convenience barriers for these communities. Moreover, large areas in these States including towns are under the control of Alshabaab who released a statement banning the use of COVID-19 vaccine in their territories.

Short vaccination days: The 10 days vaccination programme without pre- listing of vaccine recipients and putting in place robust registration and monitoring system was very ambitious

but too short to deliver the planned vaccination of 300,000 people.

Lack of adequate awareness and community mobilization: The vaccination programme was rolled out without significant prior exposure, awareness raising and community engagement mobilization. The vaccination programme was launched amid tense political wrangling over the Federal elections.

Misinformation and disinformation –

Misinformation and disinformation about

COVID-19 vaccine safety and effectiveness is a global problem and ranges from false information about the side effects of the vaccines such as infertility to conspiracy theories about population control by implanting vaccine microchips into people. In Somalia, mistrust surrounding the rapid development and authorization of COVID-

19 vaccines and whether the vaccines contain any non-halal ingredients are compounded by genuine concerns about the side effects of Oxford/Astra Zeneca jab.

• CASE STUDY: BADHADHE Rejection of COVID-19 Vaccination Shots

Badhadhe administrative district is located in southern Lower Juba Region of Jubaland State of Somalia. Badhaadhe, the district’s main town and its administrative center, has been under Alshabab control since 2017 but the coastal towns, villages and islands are administered by the government of Jubaland. The marginalized ethnic Bajuni minority community, who primarily inhabit the coastal settlements and islands, do not get adequate access to social services i.e. education, health care and clean water. These are no mobile phone and internet services in these areas and the Bajuni community rely on the traditional media particularly BBC Somali & Swahili as the only and well-trusted source of information for daily news.

As part of the COVID-19 vaccination campaign, Jubaland MoH allocated four health facilities in the Badhaadhe district area and deployed the vaccine and other necessary supplies required to inoculate the people along the coastal settlements and islands but the vaccination campaign has met with strong resistance from the community. On top of the complex geographical, social, economic and cultural factors pertaining in the subgroup vaccine hesitancy, the roll-out of the COVID-19 vaccine in these coastal areas was impeded by vaccine safety concerns after the news broadcast by BBC Somali and Swahili about the emergence of the rare but severe blood clotting adverse effects possibly linked with Oxford/AstraZeneca vaccine and the limitation of its use in many European countries in March 2021. The news might have entrenched the community’s already distrust in authority, health professionals and vaccination programmes. Concurrently, Alshabab which control large swaths of inland of Badhadhe district issued a statement warning against the use of the COVID-19 vaccine due to reported side effects.

Opportunities

Potential opportunities exist for the scale up and effective delivery of COVID-19 vaccination programme and at the same, strengthening the country’s health system in the longer term, including:

1. The existing network of hospitals, primary and referral health centers
2. The financial and technical support from GAVI to expand the existing cold chains which will improve the storage and distribution capacity across the country and strengthen the necessary capability for mass and routine vaccination programmes.
3. Lessons learnt from previous routine and mass vaccination campaigns such polio eradication campaigns.
4. Vibrant private health sector which, although largely unregulated and densely located around major cities, could offer much needed facilities and human resources to vaccinate large number of people in a short period of time.

Conclusion

Strenuous efforts were made to ensure COVID-19 vaccination programme readiness in Somalia and setting up the necessary regulatory frameworks to meet the conditions for singing up and receiving assistance through CCVAX facility. The collaboration between the Federal and Federal Member States MoHs has been instrumental in the vaccine rollout across the country but building and sustaining the capacity for COVID-19 mass vaccination is a huge task. Limited vaccine supplies, funding constraints and the country’s weak health system are hindering the efforts to accelerate the pace of vaccination and threaten the implementation  of  the  government’s

ambitious COVID-19 vaccine deployment plan.

The huge disparities in vaccine access between rural and urban communities, between IDPs and settled residents and between men and women must be addressed urgently in order to alleviate the existing deep-rooted health inequalities among Somali society.

Expanding the health existing infrastructure, improving the regulatory frameworks and building the capacity of the health workforce have the potential to strengthen the health system and produce long-lasting solutions and resilient institutions to respond to the ongoing COVID-19 crisis and beyond to future public health challenges.

Recommendations

1. Somalia health authorities need to develop sustainable short- and long- term financing strategy for COVID-19 vaccination programme to fund the operational cost of the vaccine rollout and secure sufficient doses to vaccinate 70% of the population with the support of COVAX, the World Bank, African Union and the country’s development partners and donors.
2. Somalia should build on the great work, and growing experience of its public health service and utilize its widely distributed network of primary and referral health care centers to deliver effective COVID-19 vaccination programme. An appropriately designed mixed delivery model linked to the prioritization of groups is needed to ensure equitable access to COVID-19 vaccine and urgent scale up of vaccine delivery to rural, hard to reach and vulnerable communities such as IDPs camps in order to

increase the convenience of being vaccinated. The model should be comprised of;

1. Expanded COVID-19 vaccination campaign days, preferably weeks, not days
2. Ongoing COVID-19 vaccination programme that is fully integrated into the primary health care services
3. Mobile and outreach services for rural and hard to reach communities, IDPs and refugees. For the nomadic areas, COVID-19 vaccine could be conditioned to deliver alongside with livestock treatments and vaccinations.
4. The use of private health providers, specifically big hospitals, to ramp up vaccination activities.

3. Health authorities should generate demand for COVID-19 vaccination by developing and implementing evidence-based COVID-19 vaccine communication and social health marketing strategy with particular focus on the highest risk target groups; front-line health workers, older people with underlying health conditions and the less-informed, vaccine hesitant and resistant population segments.
4. Collaborations at international, national and local levels is key to the success of the COVID-19 vaccination programme. Through the work of the National Coordination Committee for COVID-19 pandemic, strong partnership between MoHs and key international and local stakeholders such as civil society groups, private health providers, the UN and international NGOs could be established to harmonise the efforts

to increase COVID-19 vaccination programme uptake and reduce vaccine hesitancy.

5. The country needs to build a broad partnership of the whole society approach for the COVID-19 vaccination. Engage and mobilize profit and non-for-profit private sector to harness their resources and to complement public sector work. The private sector does not only provide additional resources and workforce for the provision of COVID-

19 vaccination services, but also greatly contribute to the demand generation through community awareness and education.

6. A range of community engagement interventions, including local community involvement in planning and decision making, working closely in partnership with various stakeholders and continuous monitoring and evaluation are necessary to effectively promote positive heath behaviors and improve long term health and social support outcomes in relation to COVID-19 vaccination:
   1. Health care practitioners are trusted source of information and can promote vaccination acceptance by providing complete, accurate and accessible information, taking people’s concerns into consideration and supporting them towards informed decision making.
   2. Considerable efforts should be made to detect and debunk disinformation and misinformation related with COVID-19 vaccine, and most importantly the false statements made on social media channels such as Facebook and Twitter   by   the individuals,

journalists, political and community leaders.

1. The use of variety of communication tools and formats such as traditional media, and information and communication technologies could ensure that diverse groups are targeted with the relevant and appropriate messages about the COVID-19 vaccination. For instance; BBC Somali Service and VOA Somali radio programmes are trusted sources of information for rural communities and those in remote and hard-to-reach areas and, together with local private and commercial media channels, could be used to reach large audiences and provide targeted public service announcements about COVID-19 vaccination programme. Social media channels such as Facebook and twitter could be tagged with evidence-based information and public health messages about COVID-19 vaccination programme. Appropriate information and education materials such as poems, songs, short radio dramas and visual aids should be developed for people with low literacy, persons with disabilities and other vulnerable groups.
2. Traditional and religious leaders (Imam’s in mosques) and other influential members of the society have greater access to the community and can play a critical role in the promotion of COVID-19 vaccination programme by taking the vaccines themselves as role models as well as influencing community decisions about vaccine acceptance through raising awareness of, and dispelling the misinformation about, Covid-19 vaccines. The MoHs need to engage with these respected leaders and members and equip them with appropriate and accurate information about Covid-19 vaccines.