Toward Domestic Health Financing in Somaliland: A Systematic Review of Instruments, Institutions, and Reform Conditions

This paper examines health financing reform in Somaliland, a self-governing but internationally unrecognised polity in the Horn of Africa facing a severe and worsening health financing crisis. It conducts a systematic review of evidence on health financing reform in sub-Saharan Africa and Islamic social finance in Muslim-majority low-income settings, drawing on peer-reviewed literature, WHO and World Bank data, and P4H country profiles to identify the mechanisms, conditions, and governance requirements that determine whether financing reforms succeed or fail. The comparative evidence from Rwanda, Ghana, Kenya, Uganda, Tanzania, Sudan, and Indonesia is then contextualised within Somaliland's specific fiscal, institutional, and epidemiological landscape, characterised by over 90% external financing of essential health services, out-of-pocket payments accounting for 44.9% of total health expenditure, and near-total exclusion from multilateral financing mechanisms. The paper further analyses the ten commitments of Somaliland's first National Health Financing Summit communiqué (Hargeisa, November 2025) against a four-dimension framework of evidence alignment, institutional prerequisites, sequencing feasibility, and governance requirements. On the basis of this analysis, the paper identifies five sequenced implementation priorities, legal and strategic consolidation, information infrastructure, phased insurance and cost-sharing reform, external assistance alignment, and accountability architecture, whose interaction determines whether the Summit's political commitments translate into durable institutional change within the 12–18-month policy window the comparative evidence identifies as decisive.