Family Medicine: Step-by-Step in Somaliland

In June 2024, I (F.M.N.) was selected as an American Board of Family Medicine Montegut Global Scholar to attend the WONCA Africa Region conference in Nairobi, Kenya, and to present the story of Somaliland family medicine. I believe our story typifies the best of global family medicine while recognizing the great challenges each nation faces. My hope is to promote collaboration as we learn from one another.

For some historical context, Somaliland suffered from civil war and the collapse of the central government in 1991. It is a self-declared independent and peaceful de facto state located in the northern part of Somalia, not yet receiving recognition internationally as an independent nation. Amoud University (AU), founded in 1998 as Somaliland’s first university, used the principles of peace and development to provide education and skills for professionals who could contribute to the nation’s reconstruction and growth. In 2000, AU created the first medical school, representing the beginning of formal medical education in Somaliland. The inaugural class graduated in 2007, the first in the region since the conflict disrupted education.

Recognizing the demand for highly trained doctors, AU collaborated with family medicine faculty from the United States and established a residency program in 2012. I was a member of that inaugural class. This program was the first postgraduate program in Somaliland, aiming to equip locally trained specialists to provide evidence-based medicine through holistic, comprehensive, coordinated, and cost-effective health care for individuals, families, and communities. The residency program addressed a critical gap in medical training and elevated health care standards. Our family medicine program remains the only one of its kind in the country, reflecting AU’s commitment to enhancing medical education and improving health outcomes.

Family medicine graduates opened new avenues for health care access and delivery to the Somali people and changed the health care landscape within Somaliland. To date, 47 family doctors have graduated. As a small group of colleagues, we continue to follow one another’s careers. Thirty-six (76%) of my colleagues remain within Somaliland or Somalia. Many work in public hospitals, often in management positions. Like a lead camel, my family medicine colleagues oversee neonatal intensive care units, direct the government’s dialysis programs, coordinate medical care for high-risk obstetric patients, and manage hospital departments. We model family medicine values while leading health care teams including positions such as program director of the family medicine residency, dean of the medical school, and hospital director.

Family medicine’s integration in both public and private sectors enhances the quality of primary health care services available in communities. More than half of the family medicine graduates practice in both private and public arenas. This integration of public and private practices enables the community to receive high-quality affordable care in the private sector and to direct referrals to the public hospitals when patients require more specialized resources. We offer a broader range of services and holistic care to the entire family, which contributes to a more accessible and efficient health care system. This accessibility encourages individuals to seek care earlier, reducing the burden on specialized services.

Furthermore, family physicians fill a vital role through education. By sharing our expertise through teaching, modeling, and supervising, we enhance the educational curriculum for medical and other preprofessional health students. We inspire students to follow our footsteps into family medicine careers, cultivating a new cadre of providers dedicated to primary care.

Despite strengthening the health care system, as a young specialty, family medicine faces substantial challenges. First, a significant lack of awareness and understanding of family medicine persists at the community, health care systems, and government levels. Our position within the medical establishment remains a mystery, while the general population understands specialties such as pediatricians, surgeons, and obstetricians. However, most equate our family medicine specialists’ knowledge, skills, and expertise to the numerous general practitioners’, who completed only their undergraduate medical education and intern service. Compounding this problem, many practitioners (ie, community health workers, lay midwives, nurses, and even students) dispense health care advice and medications, making determining who is qualified to provide safe and effective health care difficult for patients and families.

Additionally, our national health care system has not developed an official role for family doctors within the primary care framework. The Somaliland government implemented the Essential Package of Health Services (EPHS) to guide public health care delivery over the last 15 years. EPHS operates at four care levels: primary health units and health centers (both offering primary health care through nonphysician providers); primary hospitals (district hospitals or referral health centers) staffed by general practitioners; and regional hospitals, which focus on specialist care. Although family doctors work in primary and regional hospitals, we often are hired to work in one department, severely limiting our practice scope. As specialty-trained physicians return from training abroad, the family physicians who held these roles and provided the links back into the communities have slowly been replaced. These practices constrain family medicine’s growth within the national health care system.

Another challenge to us as a professional group and to our patients is that the national licensing board has not recognized family medicine as a specialty. We receive the same licensing status as general practitioners. This policy not only negatively affects the development and support for family medicine as a discipline but also hinders enrollment of new residents. Potential residents are reluctant to join a program lacking national recognition, often preferring to travel abroad for a more easily recognized specialist certificate.

Despite facing numerous challenges, my family medicine colleagues and I heard stories of hope and received encouragement as we listened to others’ voices at the WONCA Africa Region conference in 2024. Other African programs faced struggles like ours in achieving national recognition. Following their lead, as Somaliland family physicians, we are working toward WONCA membership. Simultaneously, we are actively engaged in advocacy efforts with Amoud University at the national level to raise awareness among policymakers about family medicine’s role in strengthening health care systems. In addition to seeking national recognition, we aim to influence policy decisions that integrate family medicine into the broader health care framework. Over the past dozen years, we have achieved significant progress in improving primary health care delivery, health-systems leadership, and medical education. This determination and advancement have had a remarkable impact on our communities. Our plan is for Somaliland family physicians, like young camels, to follow the steps of others as we overcome challenges while advocating for improved primary care for our health system and directing the path for family medicine in the years to come.

Dr Fathia Mohamed Nour gave an oral presentation at WONCA Africa Region meeting on June 7, 2024, entitled “Beyond A Decade: Successes and Challenges of Family Medicine in Somaliland,” which included a brief review of some of the successes and challenges included in this essay.

Dr Mohamed Nour was the recipient of the American Board of Family Medicine 2024 Montegut Global Scholar award, which provided her with financial assistance to travel to and attend the WONCA Africa Region meeting in Nairobi, Kenya, in June 2024. The authors have no other financial relationships or conflicts of interest to disclose.