Somalia is situated in the northern most region of the Horn of Africa with an estimated population of about 16 million out of which 60% are below the age of 25 years making Somalia one of the youngest nations in the world . The country’s population is generally homogenous in terms of language, culture and religious background, with the overwhelming majority speaking the Somali language. Somalia is politically and administratively a federated country with five regional states namely: Puntland, Jubaland, Galmudug, South West and Hirshabelle. In addition, Somaliland, situated in the north, self-declared independence in 1991 after the collapse of the central government. Somaliland has yet to gain international recognition.
The country has been without an effective national government since the collapse of the military regime in 1991. The disagreement to form a unified government led to inter-militia conflict, which expanded to inter-clan conflict. This unprecedented fall out between the major clan groups claimed thousands of lives, uprooted communities, and displaced millions internally and externally . Alongside the inter-clan conflict, war evolved and attracted different international, regional and local actors including violent militant groups, such as Al-Shabab .
Years of conflict, natural disasters, famine and insecurity, all have contributed to very low scores for most humanitarian indicators, suffering from poor governance, protracted internal conflict, underdevelopment, economic decline, poverty, social and gender inequality, and environmental degradation [3, 4]. Despite high mortality caused by civil war and famine, Somalia’s population is growing rapidly due to a high fertility rate (more than six children per woman) and a considerable proportion of people of reproductive age. With each generation being larger than the prior one, Somalia’s population puts a strain on the country’s poor health care and social services [1, 3, 5, 6].
Because about 60% of Somalia’s population is younger than 25 years and were born during the civil war, they do not know what it feels like to live in peace as conflict has been ever-present throughout their lifetime.
Studies of adverse childhood experience have shown that a high prevalence of early childhood trauma causes long-term health effects in adulthood .
In Somalia’s recent history, mental health services barely existed as part of the larger government-run health care services . Despite the existence of few colonially built psychiatric units, mental health services were largely outside the purview of the government-run health care services. As such, most Somalis depend on family and community support for mental health and rely on the services of traditional and spiritual healers for treatments [3, 8–10]. One of the biggest casualties of the civil war was loss of essential human resources in health care as most either fled the country or were victims of the war . As such, the country is in a serious situation of dealing with acute and chronic shortage of health professionals. Such a shortage is more profound in the field of mental health where only a handful of professionals provide services across the country .
In addition to armed conflict and insecurity, the country has faced climate-related shocks, mainly drought and flooding, displacing about 2.6 million people and exposing them to multiple risks . Currently 5.4 million people – more than one third of the population – are in need of humanitarian assistance . This situation has led to widespread psychosocial trauma, social deprivation and substance abuse, with devastating consequences on mental health. According to a situation analysis by the World Health Organization (WHO) in 2010, Somalia had one of the highest prevalence of mental health problems in the world with one third of Somalis afflicted with some form of psychological disorder [3–6]. However, despite these grim statistics, there is utter lack of mental health services in the country with only five low-capacity psychiatric units mostly situated in Somaliland, the relatively stable region [3, 4].
In a country with a fragile health system and ill-equipped formal institutions, affected individuals often seek help from traditional and spiritual healers while others resort to self-medication, substance use or other potentially harmful coping strategies [3, 12]. In the Somali cultural setting, mental health has largely been perceived in binary perspectives of a person being either normal or mad. In this regard, the notion of a continuum of mental health issues ranging from mild, moderate, to severe simply did not exist as part of the cultural and linguistic nosology. Beliefs in the causes of mental illness and treatment in the country are predominately metaphysical and spiritual [3, 4, 9, 12]. Additionally, significant stigma and discrimination in the society conceals mental health issues [3, 13]. Consequently, mental health services are woefully lacking, and human rights abuses are common including chaining or caging at home [3, 13]. WHO estimates that 90% of people with serious mental health problems were chained at least once in their lifetime .
Continuous humanitarian crises have had a devastating impact on the Somali civilians. Conflict-related trauma, poverty, unemployment and rampant substance abuse in the country has elicited an explosion of mental health problems . The health care system in Somalia has never developed beyond providing the most basic functions and has negligible capacity to manage monumental challenges of mental health [3, 4].
Mental health and substance use disorders are specifically included in the United Nations Sustainable Development Goals (2015–2030) . The WHO’s Mental Health Strategy and Action Plan (2013–2030) has also set a range of targets aimed at achieving equity through universal health coverage (UHC). Due to the long neglect of mental health issues in Somalia, only few partners operate in this area of work. Since 2011, the WHO, in collaboration with the non-governmental organisation (NGO) Gruppo per le Relazioni Transculturali, has worked in mental health [15, 16]. In partnership with Gruppo per le Relazioni Transculturali and Habeeb Mental Health Foundation, the WHO Somali Office launched the Chain-Free Initiative in Somalia. The Initiative aims to increase access to mental health services (facilitating humane treatments in hospitals, at home and in communities), combat discrimination and decrease the number of patients living in chains .
Research has shown that improving mental health of the population guarantees wellbeing and social, humane and economic capital of a nation [17, 18]. The mental health crisis in Somalia requires that government, policy makers and practitioners comprehend the magnitude of the factors that moderate them.
The main aim of this study is to assist mental health professionals, policy makers, government and humanitarian actors in setting priorities for the design and delivery of interventions to promote mental health and psychosocial wellbeing in Somalia.
The study’s objectives are:
to review existing literature (peer reviewed, grey literature and reports) of mental health in Somalia using a systematic mapping technique;
to assess the mental health system and other mental health determinates in the context of Somalia;
to examine, from the existing literature, the impact of the long-standing conflict on the mental wellbeing of Somalis;
and finally, to propose a framework for priority setting for mental health in Somalia that can translate to other conflict-affected settings.