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This fear is almost certainly warranted. In December, Boko Haram reportedly bombed the offices of 
the Borno State National Program on Immunization in the state capital of Maiduguri. Motives for the 
attack are not clear, but it highlight the fact that Boko Haram, or at least factions within it, view any 
government building as a legitimate target.133 There are also rumblings that the Nigerian government 
might seek to have the military or civilian JTF carry out polio vaccinations.139
Operational issues 
Lack of coverage and monitoring of vaccination campaigns 
Evidence from interviews, in conjunction with existing literature and reports on the subject, suggest 
that rather than randomly missing some children each year, vaccination campaigns are consistently 
missing the same children and households with each round of immunizations.135 GPEI has stepped up 
efforts to strengthen micro-plans that drill down to individual households to ensure all children are 
vaccinated and are increasingly incorporating GPS and GIS technology to track the movement of 
vaccination teams and identify areas, communities, and even individual homes that have been 
missed.m
But despite these efforts, there are glaring weaknesses in monitoring and evaluation. A preference 
for frequent, almost continual rounds of vaccinations by influential donors and implementers might 
be hindering overall abilities to evaluate programs. The "shotgun approach," while understandable 
given the desire to eradicate polio as soon as possible, runs counter to the goal of targeted 
interventions ?  Interventions need to be precise, but collecting the requisite information that would 
allow for precision has not been done and probably cannot be done unless vaccination rounds are 
carried out less frequently.13a
Limited financial oversight and overabundance of cash is distorting the healthcare market 
Both NGO representatives in Abuja and interlocutors in the field warned that despite the persistence 
of polio in northern Nigeria, there is probably more money being poured into Nigeria than is 
necessary for eradicating polio. This overabundance of cash may be distorting the "public health 
marker and allowing local governments to misappropriate funds while still carrying out polio 
eradication programs at a minimum. The release of funds are regularly delayed, which in turn 
disrupts planning and implementation. It may very well be that local governments and NGOs view 
polio eradication as a funding mechanism rather than an actual goalw
In its most extreme form, the abundance of money tied to polio eradication efforts may be providing 
perverse incentives. At this point, polio eradication is a full-scale, multi-million dollar industry. There 
are offices and NGOs that exist only because of the campaign. There are drivers, cooks, and cleaning 
staff and perhaps entire patronage networks who depend on the continuation of polio eradication 
campaigns. It is an open secret that some organizations might purposely fail to monitor their work so 
that polio eradication campaigns will continue. For this reason, levels of non-compliance might be 
"3  Jennifer G. Cooke and Farha Tahir, 'Polio Eradication in Nigeria: The Race to Eradication' CSIS Global 
Health Policy Center, February 2012. 
134 Interview with diplomat in Abuja, December 2013. 
135 Interview with NGO officials and diplomats in Abuja, December 2013. See also: Jennifer G. Cooke and Farha 
Tahir, "Polio Eradication in Nigeria: The Race to Eradication," CSIS Global Health Policy Center, February 2012. 
ne Jennifer G. Cooke and Farha Tahir, 'Polio Eradication in Nigeria: The Race to Eradication' CSIS Global 
Health Policy Center, February 2012. 
737 Several interviewees in the public health sector referred to initiatives that encouraged wide-ranging, 
near constant rounds of routine immunizations as the "shotgun approach," in contrast to more precise 
targeting of certain communities. 
138 Interviews in Abuja, December 2013. Interviews in northern Nigeria, January 2014. 
139 Interviews in Abuja, December 2013. Interviews in northern Nigeria, January 2014. 
41 
EFTA00615236

inflated and households missed by immunization rounds may be over-reported, so as to ensure that 
funding streams continue. In this sense, there are some perverse incentives to not eradicate polio1°0
• 4C Interviews in Abuja. December 2013. Interviews in northern Nigeria, January 2014. 
42 
EFTA00615237

Recommendations 
Healthcare Infrastructure 
Improvement of overall healthcare service through polio vaccination campaigns 
1. Improvement of overall healthcare services: Polio vaccination campaigns need to be part of a 
broader push for better governance and better health service delivery. This does not mean that 
immunization rounds need to be put on hold, but it does require that polio vaccination 
campaigns have to be embedded within efforts to bridge gaps between the government and the 
governed. Absent these efforts, frustrations with translate into "polio fatigue" and vaccine 
rejection. One option would be to provide additional healthcare services (medication for 
diarrhea, malaria etc.) through vaccination personal in order provide broader health care service. 
2. Targeted healthtcare infrastructure improvements: For a higher impact strategy, targeted 
improvements can be made of healthcare infrastructure in communities that are distrustful of 
the state, though this runs the risk of exacerbating suspicions of motives, and creating new 
tensions between districts. 
Public Opinion 
Involvement of stakeholders & communication strategy 
3. Assessment of public opinion on community level: Determining the public opinion on 
community level will be necessary in order to review and reassess current communication 
strategies and campaigns for different regions. 
4. Participatory polio campaigns: Immunization programs should continue to be participatory 
and involve state and local governments, community leaders, and traditional rulers such as 
emirs, political leaders who are elected and religious leaders. Civil society groups, even those 
outside the purview of health should be mobilized. In some areas, Polio eradication is on the 
right trajectory. Continued efforts in sensitization should be maintained and a radical rethink of 
strategy is not required. The merits of polio vaccines should continue to be diffused through 
these formal and informal networks, such as community radio, television, pamphlets, religious 
ceremonies and cultural events. 
Security Context & Scenario Analysis 
Setting up a network to gather information about the security situation on LGA and ward level 
5. Improve security awareness in key districts: In much of northern Nigeria, but specifically 
Borno and Yobe states, polio eradication needs to be placed in a security context. Polio 
eradication is not a neutral enterprise. Though eradication efforts have made great strides in 
realizing that "being right is not enough," within the context of politics and culture, perhaps it is 
time to start thinking where polio eradication and public health fall within the security sector. 
Attacks by Boko Haram, as haphazard and nihilistic as they seem, are not random. Local 
interlocutors should be found who are able to navigate this terrain and provide GPEI with real-
time information. 
Working with the police and the army is unlikely to yield actionable intelligence. They have 
their own motives and agendas and have demonstrated a stunning inability to know much about 
the socio-cultural terrain in which Boko Haram operates. Reaching out to JTF poses a different 
43 
EFTA00615238

problem all-together, as healthcare providers are likely to be targeted if they are seen as in an 
extension of JTF. The global health community needs to find a way to gain real-time information 
about shifts in the socio-cultural terrain without "militarizing" the issue. 
One avenue that should be explored is reaching out to civil society groups, local journalist 
organizations and NGOs that are familiar with these dynamics, though not necessarily 
healthcare specialists. Setting up a network of groups that can provide information on the 
political and security situation at the LGA or even ward level would go a long way in helping the 
polio eradication efforts forecast and plan for external shocks. 
Scenario analysis and contingency plans in a crisis environment 
6. GPEI should have strong contingency plans for each LGA for how to operate in a crisis 
environment. This is potentially dangerous work, but the dangers are not entirely unpredictable. 
For the foreseeable future, contingency plans must be put in place to deal with refugees who 
flow into Niger, Chad and Cameroon. They should also be in place to deal with IDP flows as a 
result of violence stemming from Boko Haram, and election-related violence. A "wait and see" 
approach will not suffice. The health community, including donors, need to be more proactive in 
preparing to mitigate the impact of insecurity and violence in northern Nigeria. 
The GPEI has done a good job making technical assistance and advice readily available to 
program implementers, but it should work to develop ways to give "strategic" advice, which 
would include feedback loops that would better anticipate the effects of instability, whether they 
stem from political or security events. Public health professionals need to be educated on 
political and security issues of the areas in which they work, perhaps seconded to other 
organizations, where they can be trained to be able to approach diplomats, ministries of foreign 
affairs, military officers, local leaders, religious leaders and a range of other actors to better 
understand the broader conditions in which they must operate, and to mobilize the appropriate 
support in the face of new or emerging challenges. Flexibility and an ability to respond to 
realities on the ground are essential. This means coordinating with multiple actors and requires a 
willingness to mix politics, public health, and diplomacy. The toolbox needs to be diversified to 
enable a better understanding of how insecurity effects public health. 
Monitoring & Feedback 
Monitoring training for vaccination staff# 
7. Monitoring and training for vaccination staff: More robust monitoring needs to take place 
at the LGA and ward level. This means training staff to be able to carry out monitoring activities, 
as well as having independent actors who can verify or "audit" the work being carried out. A cost 
benefit analysis of diverting resources, time and energy toward monitoring rather than constant 
routine immunization rounds should be conducted. Near constant immunization rounds, or the 
"shotgun" approach may yield results and might eradicate polio in spite of the poor quality of the 
underlying public health infrastructure in northern Nigeria, but getting past the finish line is not 
enough, staying past the finish is the end goal. 
In the graph below, the various strategies laid out have been clustered according to their likely 
impact on the polio eradication campaign, as well as on their ease of implementation. Ease of 
implementation was assessed along three criteria: cost, time and risk. In particular, the issue of risk 
is pertinent for those interventions seeking to have impact in Boko Haram controlled regions. 
44 
EFTA00615239

Assessment of measures to overcome barriers to polio eradication in Nigeria 
High 
Impact/reachof 
vaccination 
campaign 
Low 
Short term strategies: 
Easy to implement with 
moderate impact 
O 
Medium term strategies: 
Long term strategies: 
Moderate difficulty of 
0
 
Difficult implementation 
implementation with 
with high impact 
medium impact 
0 
Recommendations 
1. Improve overall 
healthcare service 
O 
2. Targeted healthcare 
infrastructure 
improvements 
3. Assessment of public 
opinion on community 
level 
4. hartiopartory ado 
campaigns 
5. Improve security 
awareness in lay 
districts 
6. Contingency planning for 
insecure districts 
Easy 
7. Monitonng and training 
Ease of implementation 
Difficult 
at LGA and ward level 
Many of the recommendations, however, should be considered as basic pre-requisites for continuing 
to operate in Boko Haram controlled areas of Nigeria. The tensions in these regions are escalating 
high, and the risks to health workers, community members and considerable. 
45 
EFTA00615240

Barriers to Polio Eradication in Somalia 
A Situation Assessment 
Prepared for The Bill & Melinda Gates Foundation 
April 2014 
46 
EFTA00615241

Executive Summary 
This report is an assessment of barriers to polio eradication and potential mitigation strategies in 
order to overcome these. 
Barriers to Polio Eradication 
AI Poor Healthcare Infrastructure 
Availability of and access to health care services is very limited in Somalia leading to vaccination 
levels of <50%. In rural areas distribution of health care facilities is extremely scarce. Most of basic 
health care services are provided by private institutions and NGOs. There is limited involvement of 
the government and little local ownership of vaccination campaigns. 
ilq Unfavorable social Perception: 
Most of the people in Somalia do not see polio as one of the biggest health threats. Instead they 
highlight malaria, typhoid and diarrhea as the biggest threats and would prefer medication or 
treatment for these diseases. The general public's knowledge about polio has improved after the 
awareness campaign in 2010. However, Al Shabaab's recent public messaging effort has fostered the 
belief that polio vaccinations can cause sterility, paralysis and even HIV. 
CZ Unstable political Situation 
Somalia's political dysfunction has long been a barrier to the development of an effective health care 
system. Limited territorial control, assaults on civilians by military forces as well as low levels of 
health care and vaccination support highlight some of the weaknesses of the current government. In 
addition, a power vacuum and a multitude of stakeholders (government officials, clan elders, militias 
and Al Shabaab) increase logistical and financial complexity for NGOs and polio workers in order to 
get access to certain areas. 
M. Unstable Security Situation 
Al Shabaab poses the biggest barrier to polio eradication in the country. Al Shabaab's strength is 
diminishing, but its tactics and commanders are becoming more violent. The group is sabotaging 
vaccination campaigns, denying polio teams access to Al Shabaab controlled regions and launching 
anti-polio vaccination messaging campaigns to change the public's opinion. The reasons for Al 
Shabaab's anti-polio position are believed to be a general objection to western aid organizations, 
fears of insurgency and espionage as well as political bargaining power. 
Mitigation Strategies 
Based on the initial assessment of the situation, the following mitigation strategies are suggested in 
order to address the issues associated with polio eradication: 
A) Improving overall public healthcare by closing the urban rural health care divide and 
strengthening local governance 
Polio eradication should be framed in the broader context of strengthening local governance, 
development and access to healthcare. 
(1) Information/Attraction/Access: Pursuing an information strategy targeting rural dwellers 
would help to raise awareness of polio and demand for vaccinations. 
(2) Improving overall Healthcare services: Mobile health care units could be used to facilitate 
better healthcare availability in rural areas for the short and medium term while the 
government should develop a long term health care infrastructure plan. 
B) Changing the Public Opinion 
47 
EFTA00615242

Because the situation in Somalia is still in flux and (unlike in Nigeria) interests around the eradication 
economy are not entrenched, there is still on opportunity to shift opinions in favor of polio eradication 
with targeted campaigning. 
(3) Assessment of Public Opinion on Community Level: Determining the public opinion on 
community level will be necessary in order to review and reassess current communication 
strategies and campaigns for different regions. 
(4) Radio Strategy: Sponsor a continuing series of radio in order to raise awareness about health 
care and polio in rural and urban areas. 
(5) Mobile Health Information Strategy:  Craft mobile health programs through reverse SMS 
efforts in order to push out information and health alerts to mobile users. 
(6) Internet Strategy:  Develop a Somali language web presence that raises awareness of polio 
and seeks to clarify rumors. 
(7) Direct Engagement Strategy:  Engage with clan and religious leaders in order to change their 
opinion and the opinion of their followers. 
C) & D) Overcoming political and security issues 
(8) Partnership Strategy:  Engagement of Islamic NGOs and pharmaceutical companies while 
continuing "western" NGO work would help deemphasize the western conspiracy 
connotation of polio work and emphasize its religious legitimacy. 
(9) Media Strategy:  Start open discussions with conservative clerics and religious leaders in 
order to soften Al Shabaab's position regarding polio vaccinations. 
High 
ImPaCtrruch cd 
vaccination 
Campaign 
low 
Assessment of measurestoovercome barriers to polio iodisation in Somalia 
Short term strategies: 
Medium term ttratetes: 
1.0MIttirm strategies: 
Easy to implement with 
Ntoderatedfficulty of 
Difficult implementation 
moderate impact 
mplementatron with 
with high impact 
medium impact 
©o
O
O 
0 
Lew 
few of implementation 
Heed 
Recommendations 
1. Information/Attraction/Ac 
ten 
2. Improving overall 
heatthcare services 
3. Assessment of pubic 
°union on community 
level 
4. Radio strategy to raise 
awareness 
S. Mobile strategyto raise 
awareness 
6. Internet strategyto raise 
awareness 
7. Direct engagement 
strategyto raise 
awareness 
S. Partnersh 0 strategyto 
engage vrith Islamic 
institutions 
9. Media strategy 
In the graph above, the various strategies laid out have been clustered according to their likely impact 
on the polio eradication campaign, as well as on their ease of implementation. Ease of 
implementation was assessed along three criteria: cost, time and risk. 
48 
EFTA00615243

Table of Contents 
Executive Summary 
47 
Barriers to Polio Eradication 
47 
Mitigation Strategies 
47 
Introduction 
50 
Methodology 
51 
Background 
53 
Somalia: A Political History 
54 
Barriers to Polio Vaccination 
60 
Healthcare Infrastructure 
60 
Social Perceptions 
64 
Political Barriers 
67 
Security Situation 
71 
Mitigation Strategies 
 80 
Improving overall public healthcare by closing the urban rural healthcare divide and 
strengthening local ownership 
80 
Changing public opinion on healthcare and vaccinations 
80 
Overcoming political and security issues 
81 
Areas for Future Analysis 
 83 
49 
EFTA00615244

Introduction 
Somalia is ground zero in the global fight against  
poliovirus. Beginning with a single case in 
Polio Cases 2013 
Banaadir region in April 2013, the current 
epidemic had claimed 194 victims in Somalia by 
April of 2014.11 Another 24 victims have been 
recorded in neighboring Kenya and Ethiopia. Fifty 
six per cent of poliovirus cases worldwide in 2013 
were attributable to the Horn of Africa epidemic. 
While the epidemic seemed to have peaked in 
October, a small number of residual cases have 
been identified. The large un-vaccinated and 
under-vaccinated population in the country 
heightens the possibility that the disease will 
continue to circulate. In turn, a pernicious 
epidemic in Somalia raises the risk that adjacent 
countries could experience outbreaks. 
The outbreak of polio in Somalia is not just indicative of poor public health; it is directly related to the 
nation's deeply dysfunctional politics. Despite the inauguration of an internationally recognized 
Federal Government in August 2012, the nation has not had a government capable of exercising 
control over the entire territory since 1991. Rather, Somalia has been a zone of persistent war and 
insecurity, dominated by warlords, insurgents, and foreign military forces. Social service delivery —
including health, nutrition, and education — has been left to a host of national and international 
NGOs. The complex and at times antagonistic relationship between political actors and service 
providers in Somalia has impeded aid delivery, propelled famine, and resulted in vaccination rates 
that fall well below both regional and international norms. 
Nonetheless, while the re-eradication of poliovirus in Somalia presents an enormous challenge, it is 
achievable. Somalia has eradicated wild poliovirus twice before, despite high levels of insecurity and 
violence. For many, success in such a context is a test of the international community's ability to 
adequately address polio vaccination under extreme circumstances. As former UNICEF Executive 
Director remarked in 2004, "If polio can be stopped in Somalia, it can be stopped anywhere."' 
This report investigates the nature of barriers to polio vaccination in Somalia. Three types of barriers 
are explored: structural, social, and political. Structural barriers revolve around the lack of effective 
healthcare facilities in Somalia. Much of the healthcare infrastructure was destroyed or looted during 
the conflict, while endemic violence and threats have led some healthcare providers, such as 
Medecins Sans Frontieres, to leave the country. The second type of barrier involves societal 
perceptions. Somalis do not seem to hold the ideological aversion to polio vaccinations seen in 
countries such as Nigeria and Pakistan, where the disease is endemic. However, negative rumors 
about the vaccine abound in Somalia, complicating public messaging efforts and sparking vaccination 
refusals. Islamist groups in south and central Somalia contribute to and benefit from these rumors, 
promoting them through a vigorous public messaging campaign linking the vaccine with sterility and 
HIV/AIDS. Additionally, the social perception that polio is a disease that poses only a minimal threat 
has diminished vaccination demand. Finally, the research analyzes political barriers to polio 
vaccination are analysed. The most overt barrier to vaccination in Somalia is AI-Shabaab, which has 
exerted control over large segments of south and central Somalia for the last five years. The group 
has impeded and at times completely halted aid activity, including vaccinations, in its territory. While 
200 
150 
100 
50 
• 
<14.
"'Global Polio Eradication Initiative, Polio This Week in Somalia, Posted 
http://www.polioeradication.org/Infectdcountries/Imoortationcountries/Somalia.aspx 15 April, 2014 
142 conflictaiddcf, Sanaa Coquets Polio, Stans Nevi Vaccination Campaign, UNICE/Africa News March 29. 2CO$ 
50 
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Al-Shabaab has lost ground over the last two years, the group is remarkably resilient; making it 
prudent to assume it will continue to play key a military and political role in south and central 
Somalia in the future. Finally, the Federal Government of Somalia, backed by the African Union 
Mission in Somalia is an important political actor. However, it faces serious political and 
administrative challenges, while security in the areas under its control continues to spiral 
downwards. The report will conclude by offering some tentative mitigation strategies and identifying 
future avenues for analysis. 
This report aims to convey a nuanced understanding of the barriers that have impeded vaccination 
efforts and disincentivized families from protecting their children from poliovirus. Few analytic 
reports exist on healthcare issues in Somalia, and none touch upon the 2013 poliovirus epidemic. 
Therefore, this report fills a gap, sketching out an initial picture of what factors contributed to, and 
which continue to impact, the spread of poliovirus in Somalia. Without a better understanding of 
what Somalis believe about polio, a robust comprehension of how political dynamics in Somalia 
impede vaccination efforts, and an identification of the gaps in medical infrastructure, it will be 
difficult to definitively eradicate polio in the country. 
Methodology 
Report repaIng polo u.. 
In order to identify the 
barriers to polio vaccination 
in 
Somalia, 
a 
rapid-
assessment was carried out 
between October 2013 and 
January 
2014. 
First, 
an 
information 
review 
was 
conducted, 
involving 
a 
comprehensive 
assessment 
of all 
international 
and 
nationally available reports, 
media articles and other 
documents 
regarding 
Somalia's historical approach 
to polio vaccination, the 
current 
epidemic, 
and 
international 
responses. 
Statistical data on health, 
economic 
issues, 
and 
demographic 
trends 
in 
Somalia was also compiled 
and analyzed. 
Second, eight weeks of field 
- 
research were undertaken in 
Somalia and Kenya. Due to 
the dangers of conducting 
field research in some areas 
of Somalia, interviews were 
not conducted in locales 
under the exclusive control 
of Al-Shabaab. Rather, the 
interviews were conducted in regions in which polio has re-occurred which have recently 
experienced some degree of Al-Shabaab presence. Regions surveyed included Bari, Bay, Middle 
Shabelle, Lower Shabelle, and Banaadir. Interviews on healthcare and political issues were conducted 
51 
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flat CONS.Crile 
• 
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EFTA00615246

with several dozen community leaders, religious leaders, businessmen, and health care professionals. 
The interviews were semi-structured, in order to allow for comparison. Concurrent with activities in 
Somalia, interviews were conducted in Kenya, focused on gaining a deep understanding of 
international efforts to stem the polio epidemic in Somalia, as well as gathering information on the 
political dynamics in Somalia. Interviewees were drawn from UNICEF, WHO, FAO, EU ECHO, EU 
Commission, Conflict Dynamics International, the Rift Valley Institute, current and former members 
of Somalia's federal government, Somali journalists, and independent researchers. 
All interviews were conducted in confidence and there was no attribution to the Bill & Melinda Gates 
Foundation. 
In addition to the situation assessment 'Barriers to Polio Eradication in Somalia' similar assessments 
have been conducted for Nigeria, Afghanistan and Pakistan. 
52 
EFTA00615247

Background 
Sprawling over 637,657 square kilometers, Somalia encompasses most, though not all, of the 
ethnically Somali zones in the Horn of Africa. While the last census was conducted in the mid-1980s, 
the World Bank estimates that Somalia's population is slightly more than 10 million."' Forty four per 
cent of the population are aged fourteen or younger." Life expectancy stands at around 51 years. 
Somalia is still a profoundly rural society, with sixty two per cent of the population located in the 
countryside. However, urbanization has increased over the last 20 years, driven in part by conflict 
related displacement amongst the rural population. Forty one per cent of the urban dwellers live in 
Mogadishu, the capital and the largest urban area in the country. Roughly twenty per cent of the 
population are either internally displaced, or are refugees in surrounding countries.'" 
Poverty, exascerbated by continuing civil unrest, is a reality for most Somalis. Eighty one per cent of 
the population lives in poverty, a percentage which rises to ninety four per cent amongst the rural 
population.'" Over half of all Somalis are unemployed, with youth unemployment often considerably 
higher.'" Many interviewees in Somalia highlighted a lack of jobs, especially amongst the youth, as 
one of the key threats facing the nation. A community leader in Baidoa indicated: "I think the 
greatest threats in Bay region are a lack of economic opportunities. The people are very poor and 
they don't have a lot of livelihood means. Most depend on hand outs from family and friends."'" 
The Major Clans and Sub-Clans of Somalia 
tweed 
Newly. 
Dir
Ralunveyne 
 
X
X 
A-• 
‘-re 
Ogaden 
Meehan 
Hard 
Haber GSM 
Abgal
lase 
Gadaburn 
Blymaal 
DWI 
Maine 
Conflict in Somalia is primarily conducted amongst the patrilineal clans and sub-clans to which near y 
all Somalis belong. The five major clans are Darood, Hawiye, Dir, Isaaq, and the Rahanweyn (Digil and 
Mirifle). The major clans in turn are subdivided in sub-clans, with some, such as the Ogadeni and 
Habar Gedir wielding significant influence over national politics. In addition to the major clans, a 
number of minor clans exist. Clans represent a major political force within Somalia, with clanism 
often determining access to resources and jobs. The violence and anarchy of the last quarter century 
has increased their salience, becoming, in the words of one interviewee, "the one thing you could 
rely on."149 However, the clans have also proved to be a divisive political force. Clan rivalries and 
grievances have driven many of the conflicts — physical and political — that have savaged Somalia 
since the mid-1970s. Such conflict continues in the present day, with one interviewee noting "The 
greatest challenge to the government is bad politics, with every clan wanting to dominate; the prime 
minister was ousted because he is from a different clan to the president. The same can be said about 
all politics in Somalia.""°
While clannism is not a conflict driver per se, since 1991, Somalia's clan politics have resulted in a 
political economy convened along clan lines. Clannism has become the organising principle around 
143 The World Bank, Somalia Data, Accessible at: http://data.worldbank.orgkountnfisomalla 
144 CIA World Factbook — Somalia, Accessible at: https://www.cla.govillbrary/publicationsithe-world-factbook/geosho.html 
145 2014 UNHCR country operations profile — Somalia, Accessible at: http://www.unhcr.org/pages/49e483ad6.html 
106 Human Development Report Somalia 2012, UN Development Program, Pp. 63 
7 Ibid. 
148 Interview, Community Leader, Bay 
109 Interview, Think Tank Researcher, Nairobi 
ISO Interview, Religious Leader, Banaadir 
53 
EFTA00615248

which the state has coalesced, triggering a highly volatile greed and grievance cycle of lawlessness 
and disorder centred around the control of resources, including international aid?' 
Somalia: A Political History 
Somalia has been embroiled in civil war since the late 1970s. By 1991, a coalition of rebel groups 
managed to wrest control of the country away from President Mohamed Siad Barre, leading his 
government to collapse, and forcing him to flee. In quick order, the rebel groups — which were 
organized along competing clan and sub-clan lines — turned on each other. While some areas of 
Somalia, such as the northern quasi-states of Somaliland and Puntland — remained peaceful, clan and 
warlord based violence convulsed the southern and central regions of the country.n2 By mid-1992, 
the international community had mobilized a United Nations peacekeeping force for the country, 
tasked with ensuring the delivery of aid to the desperately needy civilians impacted by the conflict. 
This force and the two additional international military forces that followed it were generally 
regarded as ineffectual. The forces of the final mission, UNOSOM II, were withdrawn from 
Mogadishu by 1995. 
The disengagement of the international community from Somalia led to a period of low-grade 
violence throughout the late 1990s. Local governance initiatives, many based around clans and sub-
clans, appeared throughout Somalia. Many were encouraged by Somalia's neighbours; few lasted. 
The only two polities that have succeeded to any degree are Somaliland, based around the Isaaq 
clan, and Puntland, dominated by the Darood clan. 
In 2000, the Somalia National Peace Conference resulted in the formation of the Transitional Federal 
Government (TFG) .n3 Despite international support, the TFG proved to be an inept, weak, and 
corrupt institution.n4 Real power in Mogadishu and other areas of the south was wielded by a group 
of predatory warlords, whose rapaciousness hobbled efforts to create a functional economy and 
provide aid to the many Somalis in need. The Union of Islamic Courts emerged in this vacuum. A 
disparate alliance of Islamist, business, and Hawiye clan interests, the courts promised stability and 
an end to warlordism. To accomplish this, they fielded a potent militia, including a little known group 
know as AI-Shabaab (The Youth). AI-Shabaab was formed by a small group of fighters who had 
previously been associated with AI-Itihaad al-Islamiya, a Salafist group that had dissolved in the early 
2000s. Many of the group's founding members had trained or spent time in Afghanistan.°5 Their 
grudge with the warlords was largely personal, as many of the warlords, acting at the behest of the 
U.S. Central Intelligence Agency, had sought to kidnap or kill the Afghan trained Somalis. 
By 2006, the Islamic Courts had defeated the warlords and taken control of Mogadishu, as well as 
most of south and central Somalia.n6 The TFG was confined to Baidoa, in Bay region, protected by 
Ethiopian military forces?' Under the Courts' control, Mogadishu was calm and relatively safe for 
the first time in a generation. A new wave of foreign fighters arrived in Somalia in this era, 
responding to an open invitation from Al-Shabaab. The group maintained strong connections with Al-
Qaeda operatives in East Africa, relying on them for training and other support activities. During this 
period, Al-Shabaab's role within the courts grew, commiserate with its increasingly potent military 
strength, including the novel utilization of Improvised Explosive Devices (IEDs) and suicide attacks. 
15' Tuesday Reitano, "What hope for peace? Greed, grievance and protracted conflict in Somalia", Yale Journal 
for International Affairs, April 2013 
152 Mark Bradbury and Sally Healy, Endless war: A brief history of the Somali conflict, ACCORD, Issue 21, Pp. 10 
153 The International Crisis Group, Somalia: The Tough Part Is Ahead, 26 January 2007, Pp. 3 
1" The International Crisis Group, Somalia: The Transitional Government On tile Support, 21. Feb 2011, Pp. I 
'55 Stig Jarle Hansen, AI•Shobaab in Somalia: The History and Ideology of a Militant Islamist Group, Oxford University Press 
2013, New York, pp. 20 
156 The International Crisis Group, Somalia: The Tough Part is Ahead, 26 January 2007, Pp. 1 
157 Ibid. 
54 
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Elements of the Islamic Courts attacked the Ethiopian forces on December 8th 2006, prompting the 
Ethiopians to launch a full-scale offensive against them. The superior firepower of the Ethiopian 
forces devastated the Courts' militias, leading to a rapid disintegration of the organization. On 
December 281°, the Ethiopians entered Mogadishu and continued south, demolishing the Courts' 
military and political structure. Al-Shabaab was one of the few units to avoid annihilation, a feat 
accomplished by its rapid retreat into the countryside of southern Somalia. While not destroyed, the 
previously formidable organization was driven underground, harried by withering Ethiopian and U.S. 
airstrikes. By the beginning of 2007, Al-Shabaab was at the nadir of its power, far more profoundly 
defeated and vulnerable than at any other time in its history, including in the present period. 
However, Al-Shabaab was able to rebound rapidly. Between 2007 and 2008 it engaged in a vigorous 
insurgency in the countryside, while its forces menaced urban centers through bombings and other 
terrorist attacks. The group has proven adept at using fear instrumentally, both as a tactic and a goal 
in its own right, deterring popular cooperation with the TFG via targeted assassinations, bombings, 
and other attacks.158 Many Somalis, including a large section of the diaspora, viewed Ethiopia as an 
occupying power, and rallied to support Al-Shabaab's insurgency. Additionally, the group's popularity 
was buttressed by the serious failures of the TFG, which had been reinstalled in Mogadishu. 
Successive administrations had proved themselves feckless and often venal, spending staggering 
sums of money without achieving visible benefit for average Somalis. 
Another potent military actor emerged during this period, as the African Union deployed a military 
peacekeeping force to Mogadishu in March 2007. The military component of the African Union 
Mission in Somalia (AMISOM) was composed of heavily armed units from Uganda and Burundi. 
Initially, AMISOM provided security for the TFG and its facilities, enabling the Somali Armed Forces 
(SAF) to concentrate on battling Al-Shabaab. 
These efforts were ultimately unsuccessful. Ethiopia withdrew its military in late 2008, as a new 
iteration of the TFG, one based on Islamist principles, took power in Mogadishu. Like its predecessor, 
this transitional government proved, again, inept and powerless, unable to provide services to its 
citizenry or to rally military opposition against Al-Shabaab. The Ethiopian withdrawal facilitated the 
takeover of south and central Somalia by Al-Shabaab. The TFG maintained a beachhead in 
Mogadishu, protected by a sizable AMISOM force?' However, its writ extended only as far as the 
AMISOM frontline. 
Throughout 2009 and 2010 Al-Shabaab proved an able and effective administrator of the south and 
center of the country. A sharia-based criminal justice system was created, and succeeded in 
providing a degree of law and order. Bureaucratic agencies were created to deal with international 
organizations, both enabling and at times impeding efforts to provide aid to Somalis living in areas 
under the group's control. 
Al-Shabaab's power was based on both military might as well as an ability to manipulate local 
grievances to their benefit. The group's post-clannist ideology proved attractive to Somalis exhausted 
by decades of internecine conflict, enabling it to attract new recruits from areas under its control. 
Security improved as Al-Shabaab suppressed inter-clan violence and banditry. This in particular led to 
increased public support for the movement. Nonetheless, Al-Shabaab's policies — including a ban on 
music, movies, and the popular stimulant khat — were not well received in the areas under their 
control, and increased popular discontent. 
158 Stig Jade Hansen, Al-Shoboab in Somalia: The History and Ideology of a Militant Islamist Group, Oxford University Press 
2013, New York, pp. SS 
159 Ibid., pp. 100 
55 
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In August 2011, Al-Shabaab initiated an offensive in Mogadishu, aimed at conquering the city. The 
group lost decisively to AMISOM and TFG forces. The defeat signaled the beginning of a period of 
decline for Al-Shabaab. In October 2011, Kenya invaded southern Somalia, eventually seizing control 
of the southern city of Kismaayo. In February 2012, AI-Shabaab solidified its relationship with Al-
Qaeda, formally merging itself into the group.16° By late 2012, the group had withdrawn from 
Mogadishu 
and 
other 
major towns in the south 
and center of the country, 
though it continued to 
hold a few urban areas. It 
should be noted that while 
Al-Shabaab was forced out 
Mogadishu and Kismayoo 
under military pressure, it 
was not militarily defeated. 
Rather the withdrawals 
seem to have been part of 
a calibrated strategy aimed 
at force protection. 
Somalia's 
first 
internationally recognized 
government 
since 1991 
was established in the 
summer of 2012. President 
Hassan Sheikh Mohamud 
was elected on September 
12th, 
amongst 
great 
international and national 
optimism about his ability 
to navigate the multiplicity 
of challenges that face 
modern 
day 
Somalia. 
Despite the efforts of the 
Federal 
Government of 
Somalia (FGS) to increase 
its capacity, it remains cloistered within Mogadishu and a few urban areas in the south and center of 
the country, and highly dependent on AMISOM for military protection. 
AI-Shabaab remains in control of large swaths of the countryside in south and central Somalia. At 
least 1.5 million Somalis live in AI-Shabaab controlled areas, while another 1.8 million live in districts 
in which Al-Shabaab has some presence.161 Since withdrawing from the urban areas the group has 
systematically avoided direct combat with AMISOM forces, instead relying on guerrilla and terrorist 
attacks to wear down its enemies. It has again begun to use fear actively to dissuade cooperation 
with the FGS and AMISOM. As one analyst observed, the group is biding its time and 
waiting.162Epidemic Background 
16° BBC News, SomalafsaiShababtinal•Qaeda,Posted 10 February 2012, Accessible at: http://www.bbc.co.uk/news/world-africa-
16979440 
161 Calculations based on Rural Population Estimates by Region/District, UNDP Somalia, August 1, 2005. 
162 Stig Jarle Hansen, AtShaboab In Somalia: The History and ideology of a Militant Islamist Group, Oxford University Press 
2013, New York, pp. 53 
56 
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It is in this chaotic situation that the 2013 poliovirus epidemic emerged. On Thursday April 18th, a 32-
month-old child in Somalia's Banaadir region came down with sudden onset paralysis. Within the 
month, another case of paralysis was reported in Dadaab, a refugee camp in Kenya that houses an 
estimated 423,496 Somali refugees. On May 9th, the Banaadir case was confirmed as wild 
poliomyelitis (WPV1), genetically similar to strains found in West Africa. Health authorities moved 
rapidly to mitigate the emerging epidemic, initiating a vaccination drive using oral polio vaccine 
(OPV) in Banaadir and some areas of the Lower Shabelle region on May 14th.'" 
Number of Cases By Region 
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Despite these efforts, the epidemic surged. Cases increased in Banaadir throughout May, while 
sporadic cases were reported in other districts. This pattern began to change in late May, as the 
epidemic took root in Lower Shabelle, Lower Juba, and Bay. The epidemic's peak seems to have come 
in early June, when 47 cases were recorded over a two-week stretch.166 In accessible districts, most 
of those paralyzed were under the age of two. However, a surprising minority of cases involved 
children between two and ten, as well as two outlier cases who were in their teens, hinting at long 
existent gaps in vaccination coverage. 
Health authorities, led by the World Health Organization (WHO) and UNICEF mustered a robust 
response to the epidemic. Commencing with the May 10th vaccination drive, 10 vaccination rounds 
were conducted, targeting south and central Somalia, Puntland, and Somaliland. Most of the drives 
were targeted at children under 10, however, three vaccination rounds targeted all ages. 
Additionally, an all ages' vaccination drive was instituted in Dadaab."8 A robust public awareness 
campaign was also undertaken, with 1,356 mosque announcements, 46,337 community meetings, 
48,000 public service announcements broadcast over the radio, and 1,300,000 SMS messages sent.'" 
Somali political officials were high profile proponents of vaccination; the President, Prime Minister, 
and Speaker of the Parliament all received the polio vaccine in a highly publicized event at Villa 
Somalia in Mogadishu. Interviews indicate that many vaccination teams engaged in similar public 
vaccinations on themselves, and on their children. President Hassan Sheikh Mohamud highlighted 
the important goal of these publicized efforts, noting, "We do not want taboos to prevent people 
from taking the polio vaccine."167
However, not all Somali political forces supported the vaccination efforts. Al-Shabaab engaged in a 
high profile campaign against the vaccination process. The group had stymied efforts at door-to-door 
163 Somalia Ministry of Health WHO/UNICEF Somalia, Somalia polio outbreak update - October 2013 
164 Ibid. 
165 The Star (Nairobi), State U.S Fight Against Polio, June 28, 2013 
166 Somalia Ministry of Health WHO/UNICEF Somalia, Somalia polio outbreak update - October 2013 
161 Four Million Targeted in Somali Polio Campaign, Garowe Online (Garowe), June 11, 2013 
57 
EFTA00615252

vaccination in the areas under its control since 2010, due to concerns that vaccination efforts may be 
a cover for intelligence gathering activities. By 2013, 600,000-1,000,000 unvaccinated individuals 
were believed to reside in the areas under Al-Shabaab control.'" Interviews in Somalia indicate that 
Al-Shabaab's ability to impede door-to-door vaccination efforts extends even into areas under 
government control, with one interview respondent in a district firmly under Government control 
noting that the vaccinators "are also afraid [of Al-Shabaab] and they only cover the very small areas 
where they feel safe."169 Nonetheless, in some areas under the control or influence of Al-Shabaab, 
vaccinators were able to work. Interviewees and media reports indicated that low-level commanders 
at times allowed localized access for vaccination teams. Such derivation from Al-Shabaab policy has 
reportedly become less common as the movement centralizes, but as of 2013 was still possible. 
Al-Shabaab's centralization and increasing conservatism has propelled a new and more vehement 
opposition to the polio vaccination, in addition to its long-standing opposition to the vaccination 
process. Interviews and media reports indicate that Al-Shabaab engaged in an active public 
messaging campaign aimed at stirring up public fear against the vaccine itself. Most messaging by Al-
Shabaab revolved around the rumors that the vaccine causes sterility or HIV/AIDS. Al-Shabaab's 
employment of the rumors pre-dates the 2013 epidemic, but the group's public messaging against 
the vaccine seems to have become far more common during the spring and summer of 2013. 
Underlying these messages is an attempt by Al-Shabaab to tap into and politically benefit from the 
distrust by Somalis of the international community's actions and motives. 
Health authorities sought to mitigate Al-Shabaab's impact on the vaccination campaign by 
vaccinating all children who came to health and nutrituion posts in denied areas and by stationing 
vaccination teams at 289 key travel points. Reportedly, these efforts were successful, with the transit 
teams alone vaccinating some 70,000 children per week.170
By late June, cases were declining in Banaadir, even while they increased in other regions in south 
and central Somalia. Additional infection clusters occurred in Kenyan and Ethiopian border areas that 
hosted large numbers of ethnic Somalis and refugees from Somalia. Reports of poliovirus tapered off 
in the fall of 2013, with the last confirmed case in mid-January, in Somali region in Ethiopia. In April 
2014, the tally of paralytic victims stands at 218. In Somalia, thirty three per cent of cases were 
registered in Banaadir province, followed by Lower Shabelle with seventeen per cent.17' The vast 
majority of cases in the 2013 epidemic, sixty per cent, occurred in areas that have been partially or 
fully controlled by the FGS and AMISOM for over a year.'72 The dearth of reported cases in Al-
Shabaab territory despite with the large unvaccinated population in those areas, heightens the 
probability that the number of paralytic cases may be higher than what has been recorded. However, 
the distribution of recorded cases also indicates that expanded FGS control alone will not mitigate 
Somali's vulnerability to the disease. 
Despite the halt in recorded cases, there is reason to be cautious in declaring the epidemic over. 
Somalia has the second lowest polio vaccination coverage in the world, estimated at over 800,000 
children. The 600,000-1,000,000 unvaccinated people living in areas under Al-Shabaab control alone 
are a potent reservoir for the continued circulation of the virus. Compounding the difficulty, much of 
the population in Al-Shabaab territory reside in rural areas, where healthcare services have 
historically been poor and information on health issues difficult to access. Rural dwellers in 
government-controlled areas — under-reached by information awareness and vaccination efforts —
are another potential reservoir propelling a continuation of the epidemic. 
168 Interview with WHO personnel, and Somalia Ministry of Health WHO/UNICEF Somalia, Somalia polio outbreak update -
October 2013 
169 Interview, Religious Leader, Banaadir 
170 Interview, WHO Personnel, Nairobi 
171 Calculations based on Rural Population Estimates by Region/District, UNDP Somalia, August 1, 2005 
172 Independent Monitoring Board of the Global Polio Eradication Initiative, Eight Report, October 2013 
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EFTA00615253

The last time Somalia confronted a polio outbreak, between 2005 and 2007, the trajectory was 
similar to the current epidemic. An initial outbreak, concentrated in Banaadir province, led to a high 
number of paralysis cases over the first six months. Case levels declined dramatically after that point, 
though it took another year and a half before the circulation of the disease was fully interrupted. It 
should be noted that in many ways the security and political environments during the 2005-2007 
epidemic were far more conducive to vaccination efforts than those in the present day. 
Nonetheless, polio eradication in Somalia is possible. Interviews indicated that vaccine demand and 
knowledge of polio are increasing rapidly. Public and private health infrastructure is also expanding, 
delivering cheaper, more professional and more effective services. While both the social and 
infrastructural variables are subject to a glaring urban-rural divide, they display a positive trajectory. 
However, the final variable, politics and stability, is a far more pernicious challenge. 
WPV eases by acossibilly maws 
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59 
EFTA00615254

Barriers to Polio Vaccination 
Research indicates that three broad barriers have impeded vaccination efforts in those countries in 
which polio is endemic. These include infrastructural barriers (healthcare), social barriers 
(perceptions of polio and the vaccine), and political barriers (the existence of spoilers and 
governmental weakness). Each of these barriers will now be analyzed, identifying the salient 
challenges, and how they are evolving. 
Healthcare Infrastructure 
Somalia's polio epidemic is indicative of a deeply dysfunctional health sector. The dearth of 
healthcare is not new, having been a persistent challenge since the waning days of President Siad 
Barre's regime. By that point, healthcare spending had been declining since the mid-1970s, and by 
1991, only twenty per cent of Somalis had access to basic health services!" There was a strong urban 
bias in healthcare provision, a divide that persists to the present day. The ensuing civil war wrecked 
the minimal public health system that did exist, leaving those in south and central Somalia with little 
choice but to pay for private services or turn to clinics run by non-governmental organizations. 
Currently, Somalia faces one of the 
greatest gaps between healthcare 
availability and healthcare needs in 
the world. Somalia has an estimated 
four physicians per 100,000 people, 
far 
lower 
than 
the 
regional 
average.
174 
A 
similar asymmetry 
exists 
with 
nurses 
and 
other 
healthcare workers. In part because 
of limited availability, it is estimated 
that on average Somalis visit a health 
post once every eight years.' This 
has resulted in disease and mortality 
levels far above both regional and international norms. Vaccination coverage, for polio and other 
diseases is often well below fifty per cent, though there has been gradual improvement over the last 
decade. Coverage rates are often far lower in rural and remote areas. 
Previous research on Somalia's health sector has found that the key impediments to service delivery 
revolve around availability and accessibility."' Each of these issues is analyzed in turn, as well as the 
professionalization of services, to identify the challenges that exist, the improvement or 
deterioration of the situation, and the impact on polio vaccination efforts. 
The availability of healthcare in Somalia is extremely limited, despite some signs of a gradual increase 
in options. Healthcare in Somalia is provided by non-governmental organizations or private facilities. 
Treatment via traditional and religious methods is common, though interviewees were less reliant on 
these methods than in years past. However, religious leaders are still sought out by parents worried 
about the religious permissibility of Western medicine. 
The private health facilities are the most widespread and accessible form of healthcare in Somalia, 
however they offer a highly uneven level of care. Some private health facilities are staffed by doctors 
and nurses and offer decent medical services. However, the most common type of private health 
facilities are local pharmacies, which double as clinics. Interviewees were pessimistic about the level 
173 Caitlin MazzilII and Austen Davis, Health Care Seeking Behavior in Somalia: A Literature Review, UNICEF, PP. 6 
IN World Health Organization, Somalia: Health Profile, May 2013 
in  Caitlin MazzilII and Austen Davis, Health Care Seeking Behavior in Somalia: A Literature Review, UNICEF, PP. 15 
176 Ibid., PP. 19 
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