One of the primary objectives of Sustainable Development Goal (SDG) 3 is achieving universal health coverage (UHC) (SDG 3.8), ensuring that individuals have access to essential healthcare services while being protected from financial hardship when seeking medical care [1]. In other words, UHC asserts that all individuals should have access to the healthcare they need without experiencing significant financial hardship. Various indicators have been used to measure progress toward this goal across low-, middle-, and high-income countries [2,3,4]. However, there has been limited research on conflict-affected and fragile states. More specifically, only 7 of the 35 conflict-affected and fragile states have been included in existing efforts to calculate UHC performance metrics [3]. The World Bank defines such settings as those characterized by weak institutional and policy environments, the presence of a UN peacekeeping operation, or large-scale refugee flows—conditions that reflect major political or security crises [5]. The limited research in these contexts is largely attributable to data scarcity, driven by factors such as inadequate funding, the absence of up-to-date census data, and broader constraints on data availability [6]. Calculating a UHC index in the context conflict-affected and fragile states—both at national and subnational levels—is crucial, given the significant challenges these nations face in meeting SDG 3.8 and broader health-related goals.
Somalia, a low-income country, has been particularly affected by prolonged conflict. Since gaining independence in the 1960s, the nation has endured ongoing political instability and violence [7]. Decades of internal conflict have resulted in the displacement of approximately three million people, many of whom reside in camps for internally displaced persons [8]. Furthermore, Somalia ranks 23rd on the Armed Conflict Location and Event Data (ACLED) index, with security conditions described as persistently volatile [7]. The presence of armed groups such as Al-Shabaab continues to pose a major threat, and 2022 was reported as the deadliest year since at least 2018, with over 6,500 fatalities—nearly double the number recorded in 2021 [7].
Somalia’s healthcare system
The broader security situation has significant implications for the organization and delivery of healthcare services across the country. Somalia’s healthcare system remains highly fragmented, largely due to prolonged political instability. The collapse of the central government led to the formation of three separate healthcare administrations—Somaliland, Puntland, and South-Central Somalia—each with its own Ministry of Health [9]. Somaliland, located in the northwest, declared independence in 1991 but is not internationally recognized. This region has maintained relative stability and demonstrates better health outcomes compared to the other two [10]. Puntland, in the northeast, operates under a semi-autonomous government, while South-Central Somalia, the most insecure and rural region, continues to grapple with instability, particularly due to the presence of Al-Shabaab, an armed group affiliated with Al-Qaeda [9].
Healthcare services in Somalia are provided through both public and private institutions, with private providers playing a dominant role [11]. The public sector consists of both, primary and secondary healthcare infrastructure [12]. However, private healthcare facilities tend to offer better quality services, advanced diagnostic capabilities, and more experienced staff. As a result, individuals with chronic or severe medical conditions, such as cancer, often prefer private healthcare options.
The governance of Somalia’s healthcare system is shared among the federal government, federal member states, and regional administrations. Somaliland, Puntland, and South-Central Somalia collectively form 17 federal member states, each with its own healthcare management approach. While the federal government oversees healthcare regulations through the Ministry of Health, regional authorities have taken on a significant role in decision-making. Somaliland, for example, has been working on a strategic plan aimed at achieving Universal Health Coverage (UHC) [13].
A major challenge facing Somalia’s healthcare sector is the shortage of medical professionals, exacerbated by ongoing conflict and insecurity. Many healthcare workers have left the country or moved from rural areas to urban centres, leading to an uneven distribution of medical personnel [12]. The public sector struggles to retain doctors and nurses due to low wages, prompting many to seek employment in both public and private facilities [9]. Somalia has one of the lowest physician-to-population ratios, with only 0.023 doctors and 0.11 nurses per 1,000 people, significantly lower than neighbouring Ethiopia [14]. Additionally, disruptions in medical education from 1991 to 2012 have resulted in many healthcare workers receiving inadequate training [15, 16].
Beyond workforce shortages, the healthcare system faces a critical lack of essential medicines and medical supplies. Many facilities struggle with basic necessities such as clean water and electricity, while advanced medical technologies for procedures like cancer treatment, surgery, and dialysis are scarce [16, 17]. The country also lacks a centralized regulatory body to oversee drug quality and imports, which worsens these supply-chain issues [16]. During the COVID-19 pandemic, Somalia faced severe shortages due to its reliance on imported medications [8].
A key factor hindering healthcare development is the lack of sustainable government funding [9]. With only 5% of healthcare expenditures covered by the government, most financial support comes from external donors, including international organizations and humanitarian agencies [12]. This reliance on foreign aid makes long-term healthcare improvements difficult to sustain [16].
The systemic challenges in Somalia’s healthcare system impact both the provision of UHC and financial risk protection. This study aims to provide an in-depth assessment of the country’s progress toward UHC while identifying key barriers that may also be relevant to other post-conflict nations. However, due to security concerns, data collection was limited in certain regions, which is acknowledged as a constraint in this research.
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