Reframing health system development in Somalia from recovery to strategic progress

Abstract

Health systems in fragile and conflict-affected settings such as Somalia are widely characterized by prolonged disruption, limited state capacity, and heavy dependence on external assistance. In recent years, however, there has been growing debate on whether these systems are merely recovering from collapse or undergoing more deliberate forms of institutional development. This narrative review critically examines the evolution of Somalia’s health system and explores the extent to which recent changes reflect a shift from recovery toward strategic progress. Evidence indicates that Somalia’s health system remains highly fragile, with persistent challenges in governance fragmentation, weak domestic financing, and unequal access to essential health services. Despite these constraints, important developments have emerged over the past decade, including the gradual strengthening of national health policies and planning frameworks, the expansion of digital health information systems, and increasing alignment of service delivery with the Essential Package of Health Services. Health outcomes remain among the poorest globally, although modest improvements are observed in selected indicators such as service coverage and immunization. These gains, however, coexist with structural vulnerabilities, particularly high donor dependency and limited institutional consolidation. Overall, the evidence suggests that Somalia’s health system trajectory is better understood as conditional strategic progress rather than simple recovery or full resilience. This reflects an evolving system where foundational institutions are being constructed incrementally, but remain fragile and highly sensitive to external shocks. Sustained improvement will require strengthened domestic financing, improved governance coordination, and effective translation of emerging policies into equitable service delivery.