EFTA00615196

of care offered by these facilities. One community leader in Bay region remarked, "The chemists 
treating people and giving medicines are untrained and unprofessional."1" Another respondent 
indicated that the pharmacies are often first and foremost business ventures "run by untrained and 
unprofessional individuals.""8 Many interviewees did note, however, that the quality of the medicine 
offered at these facilities had improved in recent years, with counterfeit medicines perceived to be 
less common. 
Non-Governmental Organizations (NGOs) are the other large provider of healthcare services in 
Somalia. Since the collapse of the Siade Barre regime, NGOs such as Medecins Sans FrontWes, CARE, 
Intersos, and OXFAM — to name only a few — have operated throughout Somalia. Interviewees 
generally preferred NGO medical facilities, noting that they provided a moderate to high level of 
care. However, some interviewees highlighted concerns over the capacity and level of care provided 
by newly opened facilities. One health official noted, "More health facilities supported by 
International and local NGOs like ICRC have been opened but they lack capacity. Some do not even 
have the right staff; they have no training in handling the sick.""' Another observed that, "The local 
health post has medical staff and nurses who are with the Red Cross. However, they are very small 
and inadequate so the bulk of medical help is provided by private pharmacies."18° Multiple 
interviewees from regions outside of Banaadir indicated that for serious health concerns they 
typically eschewed local options, and instead travelled to medical facilities in Mogadishu, which they 
perceived to be more professional. 
SO 
45 
40 
35 
30 
25 
20 
15 
10 
5 I 
2008 
2009 
2010 
Attacks on Ald Workers 
2011 
2012 
■ Killed 
• Wounded 
Kidnapped 
In terms of access, the availability of NGO-provided healthcare is tightly tied to the shifting battle 
lines of Somalia's civil war. Many NGOs providing service have been banned from Al-Shabaab 
controlled areas, or restricted in the types of services they can provide. Such bans and restrictions 
stem from Al-Shabaab's belief that humanitarian activity is being used to spy on the group. Given this 
restrictive operating environment, Al-Shabaab's expulsion from a district is often linked to increased 
healthcare access. Additionally, the chaos and banditry that is rife throughout south and central 
Somalia have led to kidnappings, attacks, and other physical threats that have caused some health 
related NGOs to withdraw from the country, including Medecins Sans Frontieres in 2013. After 
several years of declining attacks, violence against NGO personnel rebounded in 2012. If the number 
177 Interview, Community Leader, Bay 
178 Interview, Religious Leader, Middle Shabelle 
179 Interview, Health Official, Middle Shabelle 
18° Interview, Businessman, Middle Shabelle 
61 
EFTA00615256

of attacks continues to mount, it may impede or halt the operations of the NGOs operating in the 
south and central part of the country. Such a cessation of activities can have a crippling impact on 
Somalis in need of affordable and effective healthcare. 
The overdependence on NGOs for health services and lack of local ownership of the healthcare 
situation is a key long term challenge in Somalia. While international NGOs are committed and 
courageous in their provision of health services, often in the face of great personal risk and adversity, 
their actions ultimately depend upon organizational willingness to continue operating in Somalia. 
Medecins Sans Fronti&rest (MSF) withdrawal from Somalia in August of 2013, after 22 years of 
operations in the country, exemplifies the danger of Somalia's reliance on NGOs. MSF made the 
difficult decision to withdraw due to attacks on and kidnappings of its staff members. While the 
withdrawal ensured the physical security of MSF personnel, it left Somalis who had come to depend 
on the organization for health services in a difficult position. As one interviewee observed, "since 
MSF left we have had no doctors and for any complications we have to go to Mogadishu."]81 As long 
as Somalis are dependent on external entities for their health services, the surety of accessible care is 
literally out of their hands. Therefore, increasing the capacity of the ministries charged with 
healthcare provision in Somalia and boosting their ability to plan, provide, and evaluate health needs 
in the country should be a key medium term goal. 
Additionally, the shortage of local medical personnel in Somalia was flagged by many health officials 
as a key problem in the polio vaccination campaign. Some noted that the vaccinators in their area 
were badly trained, and mishandled the vaccine. One remarked that "According to my experience, 
many professionals and learned people are not confident with vaccines storage, the people who 
dispense of the vaccines and lay people are they tend to mishandle the delicate vaccines. This erodes 
the people's confidence in the process and undermines the whole campaign."'" Another health 
official observed that when confronted with a vaccinator, parents would ask "you are not a doctor, 
why should I entrust you with my child's health?"183 Other health officials noted concerns that 
members of a single clan in their area were tasked with vaccinating the community. This reportedly 
led to vaccine refusals by members of rival clans. Finally, concerns were voiced that the vaccination 
drive was leveraged as a money making endeavor by local individuals, leading them to employ 
untrained members of the community. A doctor in Middle Shabelle indicated "the [polio] vaccination 
process is done by a man from a popular clan, who has used his influence and politics to get the 
tender to carry out the vaccination here. The man is not a medic and has no medical background. He 
employs his clansmen and -women without considering qualification and training. The WHO and 
UNICEF use him to gain access where they cannot go. The people handling the vaccines are 
uneducated and unprofessional."'" 
The health officials interviewed represented the largest bloc of critics of the vaccination efforts in 
their communities. Many of the criticisms are intimately linked with Somalia's health capacity 
challenge; after two decades of conflict there are simply not enough trained medical professionals to 
oversee and implement a mass-vaccination campaign. Epidemic entrepreneurs have exploited this, 
providing vaccinators and offering international health officials the ability to access otherwise denied 
areas. However, in at least some cases this has led to the employment of minimally trained 
vaccination teams and impacted on the willingness of some to accede to the inoculation of their 
families. 
181 Interview, Community Leader, Middle Shabelle 
182 Interview, Health Official, Bay 
183 Interview, Somalia Federal Government Health Official, Nairobi 
184 Interview, Doctor, Middle Shabelle 
62 
EFTA00615257

Finally, a large challenge for both healthcare and the vaccination efforts is the spatial distribution of 
healthcare facilities. As noted earlier, for decades there has been a pronounced urban-rural divide in 
healthcare availability. The current iteration of Somalia's civil war has exacerbated this, as urban 
areas are now primarily under government control while rural areas are controlled by Al-Shabaab, 
and are thus extremely difficult to access. Rural areas also contain the vast majority of Somalia's 
population, making the shortage of healthcare options in those zones a matter of pressing 
importance. This shortage is further magnified by the expense and difficulty of traveling for rural 
dwellers.' Research has found that in many cases the cost of traveling to a healthcare facility often 
outpaces the actual cost of medical  
care.' The poorest, those in rural 
Somalia: A Rural Society 
areas, are thus doubly disadvantaged by 
low levels of healthcare availability and 
100,00% 
a financial inability to travel to a location 
where such services are available. This 
80,00% 
lack of of medical options has reportedly 
60,00% JJJ • 
Rural 
fed into a general skepticism of western 
medecine in the countryside, as well as 
40,00% 
• Urban 
fatalism over the possibility of recovery. 
The inaccessibility and lack of health 
20,00% 
care facilities in rural areas has led to a 
0,00% 
continuing 
reliance 
on 
traditional 
1982 1987 1992 1997 2002 2007 2012 
medecinal techniques.187
The challenges posed to Somalia's healthcare system do not have an easy fix. Capacity building, 
increased availability of facilities, and novel solutions to the challenge of rural healthcare accessibility 
may all play a role. However, it is abundantly clear that the current status quo is not adequate. 
Without improvements in Somalia's health system, there is little possibility that vaccination levels 
will increase in the long term. While the surge in vaccination efforts that occurred during the 2013 
epidemic is effective in mitigating an acute outbreak of disease, it is not a durable fix. 
IBS Caitlin Mazzilli and Austen Davis, Health Care Seeking Behavior in Somalia: A Literature Review, UNICEF, PP. 19 
186 Ibid., PP. 20 
187 Interview, Former BBC Somalia Journalist, Nairobi 
63 
EFTA00615258

Social Perceptions 
Full vaccination coverage often hinges upon social buy-in to the vaccination program. In areas where 
this does not occur — such as Nigeria, Pakistan, and Afghanistan — vaccination efforts face 
considerable challenges. Three aspects of Somali society salient to the vaccination program were 
investigated: perceptions of disease risk, knowledge polio, and views on the vaccine. In each of these 
areas, the potential for change was focused upon. 
Polio research in northern Nigeria indicates that a challenge in that context is the gap between the 
urgency that national and international health authorities place on the eradication of polio and the 
level of concern that the disease evokes amongst the population. Simply put, the incidence of polio is 
so infrequent that other diseases are seen as far more pressing threats to the health of the 
population. In turn, this tends to disincentivize demand for the vaccine. A similar dynamic seems to 
exist in Somalia. 
Interviews indicate that Somalis 
do not rank polio amongst the 
most dangerous health threats 
that they or their families face. 
Only one in forty respondents 
flagged polio as a threat. Rather, 
diseases 
such 
as 
malaria, 
diarrhea, and typhoid are seen 
as challenges that are far more 
acute and damaging. There 
seems to be little variation 
amongst the different regions, 
though reports of malaria did 
seem marginally higher in areas 
close to the Shabelle River. Findings from the interviews are born out in WHO statistics. Both malaria 
and typhoid occur in Somalia at levels far above regional and international norms.188 In 2010, malaria 
accounted for seven per cent of deaths for children under five, while diarrhea accounted for sixteen 
per cent. By comparison, the 185 cases of paralysis caused by the poliovirus represent an extremely 
small sliver of childhood illnesses in Somalia. Therefore, entities tasked with eradicating the disease 
face the challenge not only of reaching a large, rural population, but also of stimulating demand for 
the vaccine by heightening Somali's threat perception of poliovirus. 
Interviewee Listing of Health Threats 
35 
30 
25 
20 
15 
10 
Common Measles 
Cold 
High 
Blood 
Pressure 
Hepatitis Typhoid Diarrhea Malaria 
While Somalis view other diseases as more acute threats than polio, they are certainly aware of the 
disease. Termed daebeyl in Somali, the acute flaccid paralysis caused by polio is traditionally viewed 
as a bad omen caused spirit possession (as one interviewee noted, it is a situation in which "someone 
collided with a linn").189 A minority of respondents also indicated that in some cases the paralysis 
was thought to be an inherited condition. To "cure" daebeyl, Somalis traditionally confined the 
paralyzed individual to a room and summoned an exorcist. The exorcist, often a religious leader, 
would attempt to dispel the possessing spirits from the victim's body by reciting passages from the 
Quran and burning herbs. One respondent also observed that in some cases healers resorted to 
"burning", a traditional form of Somali acupuncture using hot coals. Religious authorities contacted 
for this report indicated that such traditional "cures" are still used, though far less frequently than in 
years past. However, interviews suggest that there is a pronounced urban-rural information 
asymmetry; with rural dwellers believed to be far more likely to ascribe to traditional beliefs about 
supposed cures for daebeyl. 
188 World Health Organization, Somalia: Health Profile, May 2013 
189 Interviews in south and central Somalia and Puntland 
64 
EFTA00615259

Interviews suggest that the last five years have seen a dramatic change in Somali's knowledge of 
polio and their willingness to rely on modern medicine to prevent it. The urban dwellers interviewed 
were nearly unanimous in noting that their views on polio had undergone a shift. None of those 
interviewed, including religious leaders, viewed the diseases as spiritual in nature. Rather, 
respondents perceived it to be a medical disease which could be prevented. Most of the credit for 
this shift in knowledge is due to the information awareness campaigns conducted by local and 
international NGOs. One respondent remarked, "Now we take [infected kids] to the hospitals in 
Mogadishu. This is due to the information and the awareness that we have been given by the radio 
and through the dialogues we have had in the community."190 Even though few of those interviewed 
had encountered someone stricken with acute flaccid paralysis, nearly all felt comfortable that they 
would recognize the paralysis as polio, and seek appropriate medical care. However, a large number 
of respondents indicated that they generally did not know the symptoms of non-paralytic polio, 
suggesting a possible avenue for future awareness building. 
A third perceptual barrier faced by health officials tasked with eradicating polio revolves around 
vaccinations. Concern about the permissibility and safety of the polio vaccine and the way in which 
the vaccination campaigns have been conducted has hampered disease eradication efforts in other 
countries. While the social environment in Somali seems more conducive to vaccination efforts, 
challenges remain. As described earlier, Al-Shabaab has sought to impede vaccination efforts by 
claiming the vaccine is tainted, and will negatively impact the recipient - causing sterility or HIV/AIDS. 
While the group's public messaging effort against the vaccination campaign involves rumors 
commonly utilized by Islamic extremist groups in other countries, it does not seem that Al-Shabaab 
has adopted global rhetoric and employed it in the local context. Rather, rumors that the OPV causes 
sterility and HIV/AIDS are common in Somalia, both in areas previously controlled by Al-Shabaab and 
areas, such as Puntland, where the group has historically had a limited presence. A religious leader in 
Middle Shabelle observed, "Years ago people would revolt against the vaccination campaign and be 
hostile to anybody who attempted to vaccinate them. This was because they believed the vaccines 
were viruses being spread by foreign powers and that they would cause such diseases like HIV to our 
population."191 More broadly rumors about sterility and HIV/AIDS relate to a profound cynicism 
towards the actions and intentions of international actors in Somalia. One Somali political candidate 
remarked, "People in Somalia are suspicious about almost everything, especially if coming from the 
West. Al-Shabaab adds to this. People do not expect anything good from the U.S.'492
Additionally, some interviewees highlighted the belief that the polio vaccine drive is actually a secret 
drug trial by a pharmaceutical company. Reported by a health official in Bay and an interviewee in 
Bad, the rumor is reportedly promulgated by religious leaders and non-medical professionals. 
According to the health official, the intent of the rumor is to "make people think that the 
organizations doing the vaccination don't care about them."193 It is unclear how widely this rumor 
has spread. 
Interestingly, the belief that vaccinations cause autism, increasingly common in the U.S. and Western 
Europe, has also spread to Somalia. Reportedly, a member of the diaspora who returned to 
Somaliland has been active in promulgating the rumored link.194 There is little indication that the 
rumor is widely repeated or believed, with none of the interviewees in Somalia flagging the rumor as 
common in their communities. Nevertheless, the existence of the rumor is troubling, and it should be 
monitored for future spread. 
Finally, interviewees indicated that some Somalis view OPV as responsible for their children 
becoming sick. A Somali journalist explained, "Over the last three years, people didn't like [the 
Interview, Health Official, Middle Shabelle 
191 Interview, Religious Leader, Middle Shabelle 
193 Interview, Somali Political Candidate, Nairobi 
'93 Interview, Health Official, Bay 
194 Interviews, UN and NGO officials, Nairobi 
65 
EFTA00615260

vaccine]. They ran away from polio vaccination, after their children received the vaccine and felt a 
fever and headache. They realized that the vaccination itself is a virus."195 These concerns can 
present remarkably durable barriers, with one religious leader in Bad noting that he had refused to 
vaccinate his family because "my wife said her niece died after being prescribed vaccination 7 years 
ago in their village. She was adamant and I began getting a little worried because I knew the 
country's health system was in a chaos and there may have been a mistake."196 Other interviews 
indicated that some believed that the vaccine itself caused polio. This concern is not wholly without 
merit. Between 2007 and 2013, a number of circulating vaccine-derived poliovirus (cVDPV) cases 
were reported in Somalia. Given the dearth of wild poliovirus in Somalia during this time, the reports 
of vaccine-derived cases likely become a potent argument against utilization of the vaccine, further 
suppressing demand for it. 
The advent of the 2013 epidemic and the associated awareness campaign seem to have succeeded in 
minimizing concerns about the vaccine. Interviewees in Somalia were emphatic that in urban areas 
few still believed the rumors. Nearly all respondents had, when offered the chance, vaccinated their 
families. More broadly, data from the UN on vaccination acceptance and media reports seem to bear 
this out. Attempts by the UN and international NGOs to stimulate demand for the vaccine seem to 
have succeeded. One Somali healthcare worker stated "People come voluntarily to my health facility 
and ask for the OPV even though it is not available at my facility because I have not been provided 
with it. This was unheard of some years back when people did not used to trust the vaccines."'" 
Promisingly, interviews indicate that knowledge of polio and demand for the vaccine improves 
rapidly once adequate information on the disease is available. Al-Shabaab's ability to harden 
attitudes against vaccination by trumpeting rumors about the vaccine are effectiv only as long as the 
group is in control of an area previously cut off from adequate information and able to dictate the 
types of medical care and information available. It is likely that concerns about Somalis irrevocably 
turning against vaccination efforts due to Al-Shabaab's messaging campaigns are, while legitimate, 
likely overblown. Nonetheless, as we will see in the final section, political barriers form the most 
intractable of the challenges faced by the vaccination teams in Somalia. 
195 Interview, Somali Freelance Journalist, Mogadishu 
196 Interview, Religious Leader, Bari 
191 Interview, Health Official, Middle Shabellc 
66 
EFTA00615261

Political Barriers 
Somalia's political dysfunction and widespread instability have long been potent barriers to effective 
healthcare. For vaccinators, the difficulties attendant with working in a war zone have been 
magnified by the vehemence with which Al-Shabaab has publicly opposed their activities. Al-
Shabaab's efforts to erect barriers to vaccination have succeeded in producing one of the largest 
unvaccinated population groups in the region, estimated conservatively at 600,000. Despite losing 
significant territory and key urban centers since 2012, Al-Shabaab is far from a defeated entity. The 
group is still a powerful political and military force, a reality that is unlikely to change in the near 
future. Additionally, Al-Shabaab is not the only barrier to vaccination provision in south and central 
Somalia. The newly established Federal Government of Somalia (FGS) has proven to be a functional, 
yet still weak entity. The absence of effective governance in areas under the control of the FGS has 
led to re-emergence of banditry and clan-based conflict. This predation impedes and increases the 
cost of service delivery, as well as potentially foreshadowing increased conflict in areas of Somalia 
now thought to be secure. This section will explore the current political realities and security 
situation faced by the Federal Government of Somalia and Al-Shabaab, highlight the salient political 
dynamics, and identify the impact on health and vaccination provision. 
Federal Government of Somalia 
The Federal Government of President Hassan Sheikh 
Mohamud is viewed as the most effective government 
Are you optimistic about the
Somalia has had in decades. The FGS is the first 
internationally recognized Somali government since 
1991, and it enjoys de facto control over many of the 
L 
• Yes 
urban areas in south and central Somalia. Many 
interviewees were optimistic about the path the country 
• No 
was on, regardless of whether they supported the FGS 
or not. However, the FGS remains challenged by its 
limited territorial control and power, continued 
violence, low levels of support, and key political questions which remain unresolved. Each of these 
issues individually could hobble the effectiveness and durability of the FGS; collectively they make it 
difficult if not impossible to run the state. 
A key challenge for the FGS is that its writ does not extend particularly far. Though the Government 
claims de jure control of all of Somalia, its de facto control is limited to Mogadishu and some urban 
areas in the south and center of the country.19B The Federal Government/AMISOM gained significant 
territory in 2012, seizing most major urban areas in the south and center of the country, however, 
there were few territorial gains in 2013. At present, AMISOM and the Somali Armed Forces (SAF) do 
not have the manpower to significantly alter the military status quo. 
A second challenge is that the FGS does not "own" the security situation. While a great deal of effort 
has been put into the development of a new Somali army, the current force has serious desertion 
and morale problems. SAF soldiers reportedly do not receive their salaries on a regular basis, and, 
according to one former TFG national security advisor, there is reliable information that soldiers have 
resorted to selling weapons and ammunitions to Al-Shabaab in order to support themselves and their 
families. Additionally, the national military has reportedly been recruited along clan lines, which 
raises the spectre that the force will come to be seen as robustly equipped clan militia, and thus an 
army of occupation in those areas dominated by rival clans. 
future? 
198 Daniel Kebede, Somalia: Still in Transition?, Africa UP Close, Woodrow Wilson International Center for Scholars 
67 
EFTA00615262

Unable to provide security in Somalia, the FGS depends heavily on AMISOM's presence to keep Al-
Shabaab from re-taking areas currently under government control.199 Interviewees were often 
emphatically positive about the role played by AMISOM, even while their perception of the security 
provided by SAF forces was generally mixed to negative. However, reliance upon AMISOM is a 
double-edged sword for the Government. While the FGS would be militarily hobbled without it, the 
force could be a political liability. If Somalis come to perceive AMISOM as acting to advance foreign 
interests in their country, they could turn dramatically against both AMISOM and the FGS. Some 
analysts have flagged the recent incorporation of Kenyan and Ethiopian military forces into AMISOM 
as posing just such a danger.2°3
Has your security improved? 
100% 
80% 
60% 
40% 
20% 
0% 
III No 
■ Yes 
100%  
80%
60% 
40% —I 
20% — 
 
0% 
Darood 1 
Hawiye 
Digit and 
Mirifle 
• No 
■ Yes 
Third, the physical security of average Somalis is improving, but significant challenges remain. The 
majority of interviewees perceived their security as having improved. This ranged from a high of 
eighty per cent of respondents in Banaadir to a low of sixty per cent in Lower Shabelle. Broken down 
along clan lines, the Digil and Mirifle clans were most likely to view the situation as improving, while 
the Darood were the least likely to see a general bettering of the situation. It should be noted that 
President Hassan Sheikh Mohamud is Hawiye, as indeed are much of the political class in Mogadishu. 
While these numbers are optimistic, the qualitative interviews indicated that the security situation 
remains extremely precarious. One businesswoman in Lower Shabelle remarked on an increased 
incidence of robbery and rape, perpetrated by SAF units. She stated, "The threat to me is the 
constant insecurity and violence. There are explosions in Afgoi on a daily basis. There are a lot of 
women who are being raped by the government soldiers who are just militias and robbers."2°1
Similar sentiments were voiced frequently in Middle Shabelle, especially regarding robbery by SAF 
soldiers. One businessman stated "the local authority and their militias are extorting business people 
by force in the name of taxation. There is no accountability."202 There has been a reported increase in 
roadblocks, used by government forces and militias to extort travelers. According to one report, 
tariffs in one area of Hiran "have increased from $50 under Al-Shabaab control to almost $700 per 
livestock truck."20i
In addition to predation by FGS forces, politicized, polarized and violent conflicts are systematically 
resurfacing and spreading in many parts of the country. Reports from Hiran, Middle Shabelle, and 
199 Matt Bryden, Somalia Redux? Assessing the New Somali Federal Government, CSIS Africa Program, August 2013, PP. 4 
}00 Bronwyn E. Bruton, speaking at "The oi-Shabab Threat After Westgate, held at the Carnegie Endowment for 
International Peace, December 17, 2013 
}01Interview, Businesswoman, Lower Shabelle 
202 Interview, Businessman, Middle Shabelle 
}03 Somali CEWERU, From the bottom-up: Perspectives through Conflict Analysis and Key Political Actors' Mapping for the 
Central Regions of Hiran, Galgaduud, and Middle Shabelle, Pp. 8 
68 
EFTA00615263

Lower Shabelle indicate that clan-based conflicts are increasingly common.206 The national election 
scheduled for September 2016 may further exacerbate local level clan violence. 
The rise in predation and clan violence points to a central challenge faced by the Federal 
Government: its inability to ensure citizen security in the areas under its control. This is troubling not 
only for what it says about government security capacity, but also because it risks undermining 
support for the FGS. As noted earlier, Al-Shabaab's support was based primarily on its ability to 
guarantee day-to-day safety in the areas under its control. 
What do you think about the new government? 
100% 
80% 
60% 
40% 
20% 
0% 
Banaadir 
Middle Shabelle 
Lower Shabelle 
Bay 
■ Negative 
■ Mixed 
■ Positive 
The Federal Government is also struggling for support amongst Somalis. It is important to remember 
that the FGS was not voted into office via an election, but rather through a vote in the Somali 
parliament (itself unelected). Since coming into office, the Government has not done a good job at 
developing internal political capital, nor in fostering a constituency.205 Interviewees were mainly 
pessimistic about the FGS. Many indicated that they viewed it as corrupt, interested primarily in 
politics, and beholden to clan interests. One businessman in Middle Shabelle observed, "The new 
government is made up of people who care a lot about their clans and their tribes. Most of them are 
politicking at the expense of their citizens."2°6 Another interviewee underlined the danger of this 
approach, noting, "The greatest threat [for the Federal Government] is violence, because not all 
Somali clans are supporting the government. Some clans say that they are unfairly represented in the 
federal government and may rise up in arms at any moment if they are not watched carefully."207
301 Somali CEWERU, From the bottom-up: Perspectives through Conflict Analysis and Key Political Actors' Mapping for the 
Central Regions of Hiran, Galgaduud, and Middle Shabelle, Pp. 7; Somali CEWERU, From the bottom-up: Perspectives 
through Conflict Analysis and Key Political Actors' Mapping for the Central Regions of Hiran, Galgaduud, and Middle 
Shabelle, Pp. 47 
}05 Interview, Mark Bradbury, Rift Valley Institute, Nairobi 
206 Interview, Businessman, Middle Shabelle 
}07 Interview, Health Official, Middle Shabelle 
69 
EFTA00615264

Rather than building a supportive constituency, the Federal Government is seen to be fixated upon 
the design of Somalia's new federalist system. Heavily supported by political leaders in Galgaduud, 
Jubaland, and Puntland, the federalist structure would involve the creation of one or more new 
political entities in the south of the country. The FGS has been lukewarm on the implementation of a 
federal system, and has instead focused its energies on centralizing political authority in Mogadishu. 
As one interviewee stated, "The whole federalism issue is about governance, autonomy, and 
accessing international resourcesfna The focus on the federalism question has diverted the 
Government's focus from the conflict with Al-Shabaab. Despite the slow increase in the capacity of 
SAF forces, there seems little political focus on expanding government control into the rural areas of 
208 Interview, Mark Bradbury, Rift Valley Institute, Nairobi 
70 
EFTA00615265

the south. As one Nairobi analyst indicated, "There is a parallel reality with Somali politicians, they 
deal with the future as if they've got control of the country and have beaten Al-Shabaab. They are 
miles away from that in the south?09
While the Federal Government has proven to be accommodating to the current vaccination 
campaigns, the government's weakness presents a challenge for near term and long term health 
provision. In the near term, the government's weakness has led to the "gatekeeper phenomenon."210
Lower level officials have leveraged their physical control over local populations and IDPs to profit 
from the provision of aid in their area. The system is not new in Somalia, but according to the UN 
monitoring group it has become more sophisticated in recent years 2t1 The diversion of aid by the 
gatekeepers prevents beneficiaries from receiving necessary supplies, as well as impeding efforts to 
monitor on the effectiveness of service delivery. 
Additionally, the power vacuum in FGS-controlled areas has complicated negotiations by NGOs for 
access 212 While Al-Shabaab can, and often does, bar aid agencies from accessing its area, it does 
present a uniform means of negotiating for access. The existence of multiple political actors in 
government-controlled areas — government officials, clan elders, militias, and Al-Shabaab — increases 
the logistical and financial complexity of accessing these areas for NGOs. 
In the long term, the greatest danger to the vaccination efforts is the possibility that the current 
governance process, as weak as it is, will fall apart. The disintegration of the FGS would, at best, 
impede efforts by NGOs to provide vital services to Somalis. At worst, a flare up of violence along 
clan lines would lead to widespread death and destruction, increasing the vulnerability of the 
population to diseases such as typhoid, diarrhea, and polio. 
Security Situation 
Stability and healthcare are a vicious circle in Somalia. Instability, and attendant destruction of 
infrastructure, pose one of the most significant barriers to health care for Somalis. In Government 
controlled areas, poor health care access can drive popular disillusionment and disgust with the 
Federal Government of Somalia, fueling grievances and instability. In areas controlled by Al-Shabaab, 
the situation is even more complex, as the country's poor security situation makes it difficult to bring 
vaccination and other health care services to the people in rural areas, while at the same time Al-
Shabaab does not allow people to seek vaccination services at health care service stations. 
Harakat AI-Shabaab Al-Mujahideen 
Al-Shabaab is the most potent barrier to polio vaccination in Somalia. The group is the only large 
political actor that has sought to halt and sabotage vaccination efforts. Al-Shabaab's opposition to 
the vaccination campaign is motivated in part by ideological concerns, similar in many ways to the 
concerns voiced in Nigeria. The group is also motivated by fear, viewing the vaccination campaign as 
a ruse designed by Western intelligence agencies to gather information and identify the location of 
Al-Shabaab's leadership. The increasing use of drone strikes and special operations raids against the 
group have deepened their paranoia. The impact of Al-Shabaab's campaign against vaccination has 
been severe; between 600,000 and 1,000,000 individuals in the areas under their control are not 
vaccinated. It is likely that this large unvaccinated population will prolong the polio epidemic, leaving 
children paralyzed who could have been protected. 
209 Interview with Roger Middleton, Conflict Dynamics International, Nairobi 
210 Report on Somalia of the Monitoring Group on Somalia and Eritrea, 2012, pp. 9 
211 Report on Somalia of the Monitoring Group on Somalia and Eritrea, 2013, pp. 365 
212 Interview with Roger Middleton, Conflict Dynamics International, Nairobi 
71 
EFTA00615266

Increase in Al-Shabaab Attacks 
October 2012 to March 2013 
Al-Shabaab is the most resilient force in 
Somalia. Its history has been marked by cycles 
of success, overreach, and retreat. Despite 
frequent pronouncements of its destruction, 
the group has an impressive ability to learn 
from its failures, and rebound. While the 
group seems to be in a weak position at 
present, there is little chance that it is on the 
verge of collapse. Rather, it is playing a 
waiting game, wearing down AMISOM and the 
FGS through guerrilla action and terrorist 
attacks. Its history suggests that it will move 
rapidly to capitalize on any weaknesses shown 
by its rivals in south and central Somalia. 
60% - 
50% - 
40% - 
30% 
20% 
10% 
0% 
Military Attacks Assassinations 
IED Incidents 
Ideology and Leadership 
Al-Shabaab's ideology is a complex mix of Islamism, international jihadism, and nationalism. At its 
core, the group is united by Salafist ideology, an austere philosophy based on an exceeding narrow 
interpretation of the Quran. Traditionally, Somalis have not followed Salafist teachings, preferring 
instead various Sufi orders. However, Salafist movements, including Al-Shabaab, have gained 
adherents and support in the past by offering a non-clan-based, Somali identity. Their vision of a 
political system not dominated by clans has been extremely appealing for Somalis buffeted by three 
decades of clan-based conflict. AI-Shabaab's strategic evolution, however, has been driven by a 
constant struggle between those evincing an international jihadist view and those focused on purely 
national aspirations. 
International jihadist ideology has existed within AI-Shabaab since the foundation of the 
organization. Many of the group's founders were either trained or fought in Afghanistan. Upon their 
return to Somalia, connections were forged with remnant members of Al-Qaeda's mostly defunct 
East African branch. The international jihadist strain within Al-Shabaab views its mission as protecting 
the Islamic Community worldwide, anywhere it is perceived to be under threat. In this view Somalia 
is just one battle ground amongst many. The most prominent proponent of this view is Sheikh 
Ahmed Abdi Aw-Mohamed (AKA Godane), the founder of Al-Shabaab, and its leader since 2007. Born 
in 1977 in Somaliland, Godane spent time in Afghanistan before his return to Somalia. He has sought 
to internationalize the organization in part by actively soliciting foreign fighters, and in part by 
declaring formal allegiance to Al-Qaeda in 2012. 
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The nationalist wing of Al-Shabaab has voraciously criticized these goals and actions. Associated with 
Mukhtar Robow (AKA Abu Mansur) and Fuad Mohamed Khalaf, themselves founding members of the 
group, the nationalist wing focuses far more on conflict and governance in Somalia. More rooted in 
local clans than Godane's wing, the goals of the nationalists are to win political control of Somalia. 
Al-Shabaab Leadership 
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While perceived to be more moderate that the Salafists, it is perhaps more apt to describe the 
nationalists as practical. Their moderation, when it comes to issues such as vaccinations and aid, is 
driven by the desire to provide practical governance for their communities. Robow and others within 
the nationalist wing have been vehemently critical of Godane's decision to merge Al-Shabaab into Al-
Qaeda, as well as the growing centralization of the group. 
Al-Shabaab's leadership structure is currently in a state of flux. Since 2010, Sheikh Godane has been 
working to centralize the group's decision-making authority under his controlm For much of the 
group's history, decision-making involved the group's shura council, composed of key military and 
political leaders within the group. The executive shura brought together the sometimes fractious and 
disparate elements of the group, enabling criticism of Godane, discussion of strategy, and other 
disputes to be handled without threatening Al-Shabaab's unity. 
Mukhtar Robow was one of the primary leaders to push back against this centralization drive. Hailing 
from the Bay region, Robow is seen as a pragmatic moderate, more focused on the conflict in 
Somalia than the larger jihadist struggle. He and Godane have repeatedly quarreled over ideology 
and tactical questions. The conflict between the two took a dark turn during the summer of 2013 
when a military clash occurred in Barawe, Lower Shabelle. During the clash, two shura members 
(Ibrahim Haji Jama Mead and Abul Hamid Hashi Olhayi) were killed, and Robow fled. He is now 
believed to be in Bay region. His current association with the group is unclear, though reports of 
reconciliation between Robow and Godane emerged in November 2013. 
Al-Shabaab's commanders have quarreled before, with internal conflicts never impacting the group's 
operational capability. However, the killing of two senior leaders is unprecedented for the group. 
Robow and Hassan Dahir Aweys, another senior leader who fled after the clash, command significant 
clan-based constituencies. Robow's and Aweys' absence from the inner circle of the Al-Shabaab may 
well alienate their clans, impeding recruitment and other forms of support. Godane's attempt to 
wield unilateral control over the organization may well backfire. He enjoys little clan-based support, 
and is reportedly personally unpopular.n4 Unfortunately, there is little indication that the FGS has 
sought to leverage this split to politically splinter Al-Shabaab. 
213 Interviews with AI-Shabaab defectors in Mogadishu 
214 Bronwyn E. Bruton, speaking at "The al-Shabab Threat After Westgate, held at the Carnegie Endowment for 
International Peace, December 17, 2013 
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Organization and Recruitment 
Al-Shabaab has three distinct components: a political/civil administrative apparatus, a traditional 
military force, and a secret service, the Maktabatu Amniyat. The first element, the civil administrative 
and political apparatus is an often-overlooked component of the group's success. During the 2009-
2011 period when Al-Shabaab engaged in governing south and central Somalia it developed a well-
functioning, though unofficial, governance structure. A look at the titles of the administrators during 
this time is instructive. Three different group 
leaders were tasked with finances (First 
deputy In Charge of Finance, Head of 
Finance, and Treasurer), another was Judge 
of AI-Shabaab, while, ominously, a third was 
head of Kidnapping Aid 
workers for 
Ransom."' 
Underneath 
these 
leaders, 
bureaucrats engaged in taxation, policing, 
and judicial activities. The latter especially 
was multi-tiered, and created the first 
effective, centralized court system Somalis 
had known in years. Al-Shabaab formed a 
Dawa department focused on promulgating the group's Salafi brand of Islam. A subcomponent of the 
Office for the Supervision of the Affairs of Foreign Agencies, the Humanitarian Coordination Office 
(HCO) was developed to regulate international aid agencies?` This office was also involved in 
negotiating access fees leveled on international aid organizations that wished to operate in Al-
Shabaab territory. The governance apparatus was reportedly dismantled in many areas when Al-
Shabaab returned to guerrilla warfare, however, some structures — such as tax and law enforcement 
units — are still believed to be operational. 
While AI-Shabaab's service provision won public support, the group's potent military capacity has 
distinguished it in Somalia. The group's offensive capabilities are divided between two wings of the 
organization: the military and the Amninyat. The military component of Al-Shabaab is composed of 
close to 4,000 fighters, organized into 7-8 man squads."' This level has dropped dramatically over 
the last three years, due to battlefield attrition, desertions, and the defection of clan-based units. 
The group is distinctive in Somalia for paying its fighters, reportedly between $1004500 per month. 
Fighters are usually recruited in areas under Al-Shabaab control, with many joining for economic 
rather than ideological reasons."9 One analyst remarked that "its profitable to be a Shabaab in some 
regions. They provide livelihoods."9 However, Al-Shabaab does hold an attraction for Somali youth. 
An interviewee observed, "AI-Shabaab are seen as having a strong vision, which helps to draw in 
youth. Al-Shabaab believes in its goals enough that they are committing suicide for it."229 There are 
few reports of forced recruitment. Enlistees undergo three to six months of training in one of the 20 
camps that Al-Shabaab operates."' Foreign fighters reportedly conduct much of the instruction. 
12.000 
10.000 
8.000 
6.000 
4.000 
2.000 
0 
Number of AI-Shabaab Fighters 
ei N el 
el 
N 
NI 
N 
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m en NI MI 
212 Suna Times, AM:Ueda foreign operatives dominate Al-Shabaab executive council, Posted May, OS 2011, Accessible at: 
http://www.sunatimes.com/view.php?id=392 
216 Ashley Jackson and Abdi Aynte, Talking to the Other Side: Humanitarian Negotiations with Al-Shabaab in Somalia, 
Humanitarian Policy Group, Overseas Development Institute, Pp. 14 
212 Interviews with Al-Shabaab defectors in Mogadishu 
HS Interviews with Al-Shabaab defectors in Mogadishu 
219 Stig Janie Hansen, speaking at "The of-Shaba!) Threot After Westgote", held at the Carnegie Endowment for International 
Peace, December 17, 2013 
220 Interview, Former BBC Journalist, Nairobi 
221 Report on Somalia of the Monitoring Group on Somalia and Eritrea, 2013, pp. 66 
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EFTA00615269

The military component of Al-Shabaab maintains a hierarchical, though largely opaque command 
structure. Al-Shabaab reportedly maintains five operational commands, most responsible for 
multiple regions. Each command is led by a regional commander, with commanders for each region 
Military Command Structure 
Region 1 
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Middle] 
Juba 
Region 2 
Muck* 
Miran 
- 6algaduudi
Region 3 
BanaadY 
l abel
Shabelle 
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Shabelle 
Region 4 
Region S 
Puntland 
Kenya 
serving underneath him. One level down are district commanders, who have traditionally enjoyed 
broad autonomy. However, the centralization of the group has reportedly limited the operational 
discretion of lower level commanders. 222
The other offensive component fielded is the Maktabatu Amniyat. The Amniyat is a clandestine 
"organization with an organization", tasked with intelligence, counter-intelligence, and terrorist 
attacks 223 The group is also responsible for enforcing unity within Al-Shabaab, by, amongst other 
things, hunting down and killing defectors.224 They are widely feared within Al-Shabaab. The 
Amniyat's total strength is unclear, though some reports claim that in 2013 there were 200 members 
operating in Mogadishu alone.225
The Amniyat is under the direct control of Ahmed Abdi Godane, through its nominal director is 
Mahad Mohamed Ali (AKA Karate).226 Karate is an experienced militant who led the urban resistance 
against Ethiopia in Mogadishu after the fall of the Islamic courts. His control over the Amniyat is 
indicative of his increasingly important role within Al-Shabaab. Godane has reportedly used the 
Amniyat in his drive to centralize decision-making around him. 
The organization is structured "like a 
clandestine 
terrorist 
organization" 
utilizing a networked, cell based 
structure in order to minimize the 
group's vulnerability to penetration or 
arrest. The members of the Amniyat 
I 
are specially selected, with many 
possessing 
specific 
linguistic 
or 
operational 
capabilities.227 
They 
receive higher salaries than regular Al-Shabaab forces, and often operate individually or in small 
teams. Given the operational similarities between attacks attributed to the Amniyat in Mogadishu 
and attacks claimed by Al-Shabaab in Uganda and Tanzania, it is logical to presume that the Amniyat 
maintains a foreign operations wing. Some observers have noted that the Amniyat is operationally 
viable even without Al-Shabaab's military support, raising the possibility that Godane has designed 
Finance and 
Logistics 
Maktabatu Amniyat Structure 
Intelligence 
Collection 
Assassinations 
Suicide 
0pentions 
Regional 
Commanders 
222 Ibid., pp. 315 
223 Interviews with Al•Shabaab defectors in Mogadishu 
224 Stig Jarle Hansen, Al-Shaboab in Somalia: The History and Ideology of a Militant Islamist Group, Oxford University Press 
2013, New York, pps. 74 & 83 
225 Report on Somalia of the Monitoring Group on Somalia and Eritrea, 2013, pp. 58 
226 Ibid., pp. 56 
222 Report on Somalia of the Monitoring Group on Somalia and Eritrea, 2013, pp. 57 
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EFTA00615270

the group to "survive Al-Shabaab, in the event that the movement was deprived of any territorial 
control or clan and political support in Somalia, or if it split into its constituent factions."228
Foreign Fighters 
Finally, foreign-born fighters constitute another distinct section within Al-Shabaab. Foreign fighters 
have been present in Somalia since the 1990s, including elements associated with Al-Qaeda in East 
Africa .2n Reportedly, several hundred foreign fighters were serving alongside Al-Shabaab in 2006. Al-
Shabaab actively promoted the immigration of foreign fighters to Somalia, inviting them to come and 
wage jihad in the country. There have also been some reports that jihadists from other conflict areas 
— such as Nigeria — have come to Somalia to gain training at Al-Shabaab camps. There are believed to 
be roughly 300 foreign fighters in Somalia at present — primarily Sudanese, Kenyan, and Yemeni, as 
well as an unknown number if diaspora Somalis 73°
Increasingly, AI-Shabaab has also recruited fighters in East Africa. Kenya and Tanzania have been 
particularly fertile recruiting grounds. Recruits come not only from the Somali and from Muslim 
population groups in the region, but also from Muslim converts. Al-Shabaab has sought to further 
advance their recruitment efforts in East Africa by increasing their Swahili language outreach. 
Finally, Al-Shabaab has recruited actively amongst the Somali diaspora. A significant number of 
diaspora members from the United States and Western Europe have responded to these calls. The 
motivations for most have revolved around nationalism, rather than jihadism. However, a number of 
diaspora volunteers have been utilized in suicide attacks, suggesting that some element of religious 
radicalization has occurred. 
However, while Al-Shabaab has publically sought to attract international fighters to Somalia, the 
reality when they arrive is often far more difficult. The Amniyat keep close tabs on foreign fighters, 
with its intelligence agents posing as their drivers and the receptionists at foreign fighters' 
guesthouses.73! Foreign fighters are often accused of spying, and/or mistreated in some other way. 
The withdrawal of Al-Shabaab from the cities seems to have catalyzed a feeling of vulnerability in the 
organization. This has manifested, in part, in an intense paranoia towards non-Somalis. Al-Shabaab's 
hostility towards foreign fighters has led many to leave Somalia, and a few to be killed by the 
group 32 
Tactics 
Despite withdrawing from most urban areas in 2012, AI-Shabaab continues to exert control over 
large swaths of central and south Somalia. According to the UN Monitoring Group on Somalia and 
Ethiopia, these include the regions of "Middle Juba, most of Hiran, Bay and Bakol regions, and 
sizeable parts of Galgadud, and Lower and Middle Shabelle."223 At least 20 districts are controlled 
directly by Al-Shabaab.234 As of 2005, the last time population estimates were published by the UN, 
1.5 million people lived in those districts. At least 12 districts are contested, meaning the government 
228 Ibid., pp. 59 
229 Stig Jarle Hansen, AI•Shoboab in Somalia: The History and Ideology of a Militant Islamist Group, Oxford University Press 
2013, New York, pp. 43 
2"  Report on Somalia of the Monitoring Group on Somalia and Eritrea, 2013, pp. 68 
231 Ibid., pp. 57.58 
232 Interviews with Al-Shabaab defectors in Mogadishu 
233 Report on Somalia of the Monitoring Group on Somalia and Eritrea, 2013, pp. 48 
234 Occupied districts include Tayeeglow, Waajld, Xudur, Dinsoor, 8aardheere, Garbahaarey, Bubo Burto, 
Jilib, Saakow, Jamaame, Adan Yabaal, Cadabe, Baraawe, Kurtunwaarey, Qoryooley, Sablaale, Ceel Buur, and Ceel Dheer. 
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controls the urban centers and main routes, while Al-Shabaab holds control of the countryside.235 It is 
estimated another 1.8 million Somalis live in these areas. Additionally, the group expanded into 
northern Somalia in 2012, absorbing a militant force operating in western Puntland. Finally, the 
group retains a discrete though coercive presence in almost all of Somalia's urban areas. It maintains 
the ability to use fear coercively even in areas the government deems under its control. One 
community elder in Middle Shabelle observed that "security is getting worse; I have never witnessed 
such suicide attacks like I have seen in the last two years. AI-Shabaab is assassinating anybody. 
People are afraid of the darkness, they don't know when they are going to get bombed and this has 
never been in Somalia."736
Al-Shabaab has been defined by the employment of military tactics and operational capability that 
often far outstrip other Somali militia groups. For most of its history, AI-Shabaab has operated as a 
light irregular force. When matched against a heavily armed and well-trained military it has tended to 
fair poorly. Its defeat in large battles against militaries of Ethiopia, Kenya, and AMISOM highlights the 
group's weakness. However, AI-Shabaab has excelled when using asymmetric tactics and when facing 
lightly armed militia forces. One of the group's key strengths is its mobility. It is able to move its 
forces rapidly to swarm opponents, and to take advantage of tactical and strategic opportunities?' 
Guerrilla and terrorist tactics are the group's forte. Its novel employment of IED and suicide attacks 
began in 2005 and 2006 respectively, and they have continued to be a mainstay of the group's 
offensive operations. Suicide attacks have been especially favored, both for their tactical benefits, 
and for the attention that they bring to the organization. The group has shown a willingness to attack 
hard targets, including the UN compound in Mogadishu. The group has also made heavy use of 
targeted assassinations, killing military personnel, politicians, and those who speak out against it. As 
one respondent in Banaadir remarked, "There is constant threat on anybody who speaks for justice, 
you may be assassinated in your own house and so nobody will speak."138
Stance on Aid and Vaccinations 
Al-Shabaab has effectively blocked polio vaccination teams from a large segment of the population in 
south and central Somalia. The reasons underpinning this action are a complex blend of objections to 
international aid organizations, paranoid fears, centralization, and an increasingly vehement 
objection to the vaccine itself. However, the current opposition may be situationally grounded, with 
the group's actions being driven by its perception of vulnerability. If so, the group's stance on 
vaccinations is likely to be heavily influenced by its fortunes on the battlefield. 
Al-Shabaab has historically had a contentious, yet working relationship with international NGOs 
operating in its territory. During the period that it governed Somalia, a Humanitarian Coordination 
Office was established to regulate aid organizations working in Somalia. Aid agencies working in Al-
Shabaab territories were forced to pay a tax to the group to continue operating, though, at least 
initially, the organization did not significantly limit access. In at least one case, AI-Shabaab halted a 
WHO vaccination campaign in order to pressure the organization for more money.739 One observer 
noted "Al-Shabaab sees itself as a 'government in waiting', and as such has a desire to provide 
235 Contested districts Include Rab Dhuure, Baidoa, Buur Hakaba, Qansax Dheere, Afmadow, Badhaadhe, Kismaayo, 
Jowhar/Mahaday, Balcad/Warsheikh, Afgooye, Marka, and Wanla Weyne. 
236 Interview, Community Elder, Middle Shabelle 
}3' Interview, Somali Journalist, Nairobi 
}38 Interview, Community Leader, Banaadir 
233 Al-Shabab halts polio immunization activities in southwestern Somalia, Radio Bar•Kulan, Nairobi, in Somali 1600 gmt 5 
Nov 11, Supplied by BBC Monitoring Africa — Political, November 5, 2011 
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EFTA00615272

services (or be credited with their provision) and control aid distribution."200 Local commanders, 
often drawn from local clan groups, were often the most facilitating of aid activities. However, Al-
Shabaab also viewed aid agencies with a strong degree of suspicion. Expulsions, based on accusations 
of espionage, were common. 
This fear of espionage seems to have prompted the first steps by Al-Shabaab to limit vaccination 
efforts. Door-to-door vaccination drives were reportedly banned in some areas as early as 2008, 
though it does not appear a blanket ban came into place until 2010.201 The earlier date coincides with 
a US airstrike that killed Aden Hashen Ayrow, a group leader. Ayrow's killing, coupled with other 
attempts to kill or apprehend Al-Shabaab and Al-Qaeda members in Al-Shabaab's territory, increased 
paranoia within the group. The door-to-door vaccine campaigns reportedly became seen as a major 
security threat to Al-Shabaab's commanders, and hence were banned by the group's leadership. 
However, the broad operational discretion enjoyed by local field commanders allowed, in some 
communities, for discrete door-to-door vaccine drives to occur. It is important to note that the group 
at this time was reportedly not anti-vaccine. It continued to allow the vaccine to be provided at 
health posts, and otherwise did not systematically agitate against the vaccine. 
The group's defeat in the 2011 battle of Mogadishu seems to have had a strong, though indirect 
impact on the group's approach toward vaccination. First, the defeat severely weakened the group 
and made it less comfortable with taking risks, such as letting in (in its view) spies.7A2 In part, this 
prompted the group to eject sixteen NGOs in 2011, including UNICEF and the WHO. In some cases, 
the group kidnapped or threatened officials associated with the polio vaccination program.TM3
Second, after 2011 the group's centralization accelerated. District level commanders lost some, 
though not all of their ability to let in vaccination teams. Requests for access were increasingly 
referred up the chain of command for approval, and many were denied. Nonetheless, according to 
interviewees in Nairobi, in some locations district commanders continue to allow limited access.'" 
By 2013, Al-Shabaab's objections had shifted. Rather than opposing the method through which the 
vaccination campaign was conducted, it began to oppose the vaccine itself. The group engaged in a 
public messaging campaign to drive down demand for the vaccine by claiming it was part of a 
Western plot, and could well cause sterility or paralysis. While Islamic groups in other areas of the 
world commonly evince these rumors, it is unclear where in the organization the motivation for this 
stance emerged. Godane's effective purge of moderate members of the shura council may have 
given him the leeway to steer the group more towards international jihadist orthodoxy on 
vaccinations. Alternately, AI-Shabaab may be playing to its constituency, trumpeting rumors in order 
to discredit international actors in Somalia, and by default the entity that is most associated with 
them, the Federal Government of Somalia. 
Al-Shabaab's public messaging campaign against the vaccine was less a sign of strength, than of 
weakness. Messaging campaigns were primarily conducted in urban areas that have been under Al-
Shabaab control for several years. The diversion of group resources to minimize demand for the 
vaccine is likely an implicit admission that Al-Shabaab's ideology and authority are only lightly 
accepted in these zones. Rural areas are far more problematic, comprising both the bulk of Al-
24° Ashley Jackson and Abdi Aynte, Talking to the Other Side: Humanitarian Negotiations with Al-Shabaab in Somalia, 
Humanitarian Policy Group, Overseas Development Institute, Pp. 15 
241 Interview, WHO Personnel, Nairobi 
242 Ashley Jackson and Abdi Aynte, Talking to the Other Side: Humanitarian Negotiations with Al-Shabaab in Somalia, 
Humanitarian Policy Group, Overseas Development Institute, Pp. 16 
243 Somali militants threaten to kill WHO workers over polio vaccination, Radio Dalsan, Mogadishu, in Somali 1600 gmt 13 
Feb 2013, supplied by BBC Monitoring Africa - Political 
244 Interview, Somalia Federal Government Health Official, Nairobi 
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Shabaab's operational space and containing the bulk of Somalia's population. As noted earlier, rural 
dwellers are far less likely to be able to access healthcare, are more suspicious of vaccination efforts, 
and are less likely to have been reached by the awareness campaigns. Al-Shabaab's messaging may 
play into and buttress a pre-existent suspicion. Additionally, Al-Shabaab can further hamper the 
ability of these populations to travel to nutrition and health posts to access the vaccine. The 600,000 
to 800,000 children dwelling here present a potentially chronic pool for poliovirus infections, raising 
the risk that the diseases could easily reappear in Somalia's urban areas, and in neighboring 
countries. 
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Mitigation Strategies 
Improving overall public healthcare by closing the urban rural healthcare divide and 
strengthening local ownership 
Al-Shabaab is neither the root of Somalia's political conflict nor the most intractable long-term threat 
to achieving high levels of vaccination. As noted throughout the report, two key challenges threaten 
healthcare in Somalia: a lack of local ownership and a dramatic urban-rural divide in access to care. 
Urban dwellers are far more likely to have access to healthcare, information, and, in the current 
moment, accurate information on polio and on the polio vaccine. Unfortunately, urban dwellers 
currently constitute a minority of the population. Therefore, strategies need to be developed to first 
buttress the capacity of the Federal Government's service provision and second to provide 
information, healthcare services, and information to rural dwellers 
1. Information, Attraction, Access: One strategy to appeal to rural dwellers could hinge on the 
aforementioned three elements. Identify an information strategy that can specifically target rural 
populations in each of the regions, including the targeting of key decision makers. This could 
include the dissemination of low price radios, telephones, and other technology devices. Ensure 
the countryside has equal access to information, to the degree possible, as urban dwellers do. 
Additionally, utilize these channels to increase demand for the polio vaccine. This may be a 
simple information campaign, or it could use outreach through the diaspora of urban residents to 
their rural relatives. Finally, enable rural dwellers to access vaccination services. If, as some 
research has indicated, travel for health services is often prohibitively expensive for rural 
residents, consider the funding of travel for those willing to make the journey. 
2. Improving overall rural Healthcare Services: In order to deal with the urban-rural health care 
divide in the short and medium term, mobile health care units could be used to improve rural 
health care services. Remoteness and accessibility poses one of the biggest problems when it 
comes to rural health care services, therefore mobile units can be used to bring health care 
services to the people. In the long run, making health care more accessible for rural dwellers 
should be part of the countries general infrastructure and development strategy. 
Changing public opinion on healthcare and vaccinations 
Interviews in Somalia indicated that attitudes on healthcare and vaccinations are malleable. This is 
beneficial, in that it shows there is a rapid rebound in demand for vaccinations in areas that have 
been under Al-Shabaab control. However, the pendulum can also swing the other way. Multiple 
interviewees noted that prior to this awareness campaign they had not been exposed to an 
information campaign in a number of years. Many remarked that this lack of information not only 
depressed demand for the vaccine, it also made the work of the current effort all the more difficult. 
When not confronted with a dangerous disease people tend to forget the importance of vaccination. 
Therefore, it should not be taken for granted that Somali's perceptions on polio will remain 
conducive to polio vaccination campaigns. Extremist rhetoric, rumors from the diaspora, and a 
dissipating sense of urgency around the disease can re-craft the social operating environment in 
Somalia. Access to technology — radio, mobile phones, etc. — allows information to spread quickly, 
both hindering and helping vaccination efforts. 
The following strategies may be followed: 
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. It is a prerequisite for all the other information 
strategies listed below. 
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