Hidden Financial Hardship and Inequity in Health Spending: Beyond SDG 3.8.2 Evidence from Somalia

Abstract Somalia’s first official financial protection estimates, produced through the 2025 WHO/World Bank country consultation and published in the December 2025 Global Monitoring Report on universal health coverage, report that 38.8% of the population faced financial hardship from out-of-pocket (OOP) health spending in 2022 — almost entirely (36.7 of 38.8 percentage points) through impoverishing rather than merely large payments. Threshold-based indicators, however, systematically miss hardship that households finance through borrowing, asset depletion, food sacrifice, and forgone care. No study has yet measured these coping mechanisms in Somalia or examined how far official estimates diverge from household-reported hardship in a fragile state. Methods : We triangulated two sources. First, we extracted Somalia’s official revised SDG 3.8.2 estimates, components, disaggregations, and ancillary statistics (2016, 2017, 2022) as published in the 2025 WHO/World Bank Global Monitoring Report and the WHO Global Health Observatory (GHO) financial protection database, based on the Somalia Integrated Household Budget Survey (SIHBS) 2022. Second, we analysed a cross-sectional survey of 2,000 Somali households (2023–2024) capturing insurance status, banded OOP payments, cost drivers, and self-reported coping responses, from which we operationalised tiered indicators — core hardship, severe hardship, and proxy impoverishment risk — grounded in coping-adjusted measurement theory. Correlates of hardship were estimated by multivariable logistic regression. Results: Official estimates show hardship rising from 33.2% (2016) to 38.8% (2022; corresponding to approximately 6.8 million people), universal (100%) hardship in the poorest consumption quintile versus 0.1% in the richest, and rural prevalence (55.4%) nearly double urban (28.8%). In the household survey, 88.8% reported OOP payments in the previous month; core financial hardship affected 67.0% of households, severe hardship 45.9%, and proxy impoverishment risk 52.1% — a representing an additional 28 percentage points beyond the official threshold-based estimate. Borrowing (22.4%) and cutting food or necessities (21.6%) were the leading coping responses; absence of insurance (aOR 2.71, 95% CI 1.53–4.79) and payments above US$100 (aOR 18.71, 95% CI 12.73–27.48) strongly predicted hardship. Medicines constituted the largest reported driver of out-of-pocket spending (27.4%), addressing the OOP-composition gap unreported for Somalia in the official statistics. Conclusions : Somalia’s official SDG 3.8.2 estimates and household coping evidence are complements, not substitutes: the revised indicator captures the impoverishing core of the crisis, while coping-based measurement reveals an additional tier of hardship that consumption-smoothing renders invisible to thresholds — and that widespread forgone care further hides. A two-tier monitoring framework — official SIHBS-based estimation plus routine coping indicators — should anchor financial protection tracking under the Health Financing Strategy 2026–2030 and offers a transferable model for fragile states.