Health System Transformation in Somalia: An Analysis of Justice, Sustainability, and Resilience in a Fragile State

Background: Health systems in fragile and conflict-affected states (FCAS) like Somalia face uniquely compounded pressures requiring transformative approaches that prioritize equity and long-term viability. The legacy of prolonged conflict, weak governance, pervasive socio-economic disparities, and acute climate vulnerability present formidable obstacles to achieving Universal Health Coverage (UHC). This paper provides a comprehensive analysis of Somalia’s evolving health system through the critical, interconnected lenses of health justice and sustainability. Methods: A qualitative synthesis methodology was employed, involving in-depth analysis of core Somali policy documents (Health Sector Strategic Plan III 2022-2026; Somali Health and Demographic Survey 2020; Somalia Facts & Figures 2022), specialized reports addressing climate change impacts (NCEA Advice, 2021; UNDP Factsheet, 2025), and relevant peer-reviewed Health Policy and Systems Research (HPSR) literature focusing on FCAS, resilience, and equity. Thematic analysis centred on governance, financing, service delivery (Essential Package of Health Services - EPHS), human resources (HRH), health equity, and climate adaptation. Results: Somalia’s health system remains severely fragmented, characterized by a dominant, unregulated private market, underresourced public facilities, and numerous NGOs. Public health expenditure is critically low (approximately 0.18% of GDP), leading to heavy reliance on volatile external aid and catastrophic out-of-pocket payments (>25\% of households use distress financing). Profound health injustices manifest as stark disparities across geographic (nomadic 4% facility delivery vs. urban 34%), socioeconomic (poorest 20% facility delivery 5% vs. wealthiest 20% 48%), and gender (MMR 692) lines. Key indicators like skilled birth attendance (32%) and full child immunization (11%) remain alarmingly low. Extreme vulnerability to climate change exacerbates health risks and continuously undermines the system’s limited adaptive capacity. Conclusion: Meaningful health system transformation in Somalia necessitates a paradigm shift, embedding health justice and climate resilience within policy design, implementation, and evaluation. This requires integrated strategies that address structural drivers of inequity, strengthen governance for pro-poor regulation, mainstream climate adaptation, and develop sustainable financing. Politically-informed, participatory HPSR is crucial for generating actionable evidence to navigate this complexity, foster adaptive management, and support progress toward equitable and resilient health for all Somalis.