A System Under Strain: The State of Healthcare in Somalia and What Real Reform Requires

Somewhere in the Bay region of Somalia, a father named Kalimow Mohamed Nur spent seven months watching his twin sons struggle after a birth that almost cost his wife her life. She had bled heavily during delivery at home. There was no free health facility in their village, and he had no money for the journey to the nearest hospital. According to a 2024 report by Médecins Sans Frontières (MSF), who have been supporting Bay Regional Hospital in Baidoa since 2018, transportation to secondary care in that region can cost families up to $300: a figure that is simply impossible for most. Insecurity along the roads makes the journey dangerous even for those who could find the money.

We begin here because the numbers that follow mean more when you understand what they represent. They are not abstractions. Each figure corresponds to a family like Kalimow's, to a child who did not receive a vaccine, to a nurse who left for a safer country and has not come back. Somalia's healthcare crisis is one of the most serious challenges the country faces, and it deserves to be understood with the same seriousness it demands.

The Workforce Crisis: When the People Who Can Help Are Gone

Before you can fix a health system, you need people to run it. Somalia does not have nearly enough of them. According to research published in Frontiers in Public Health in 2024, around 600 medical professionals have left the country due to prolonged conflict and instability, contributing to an urban-rural divide that leaves rural and remote communities almost entirely without qualified care. The doctor-to-population ratio stands at just 0.023 physicians per 1,000 people: one of the lowest figures anywhere in the world, and significantly below even neighbouring Ethiopia.

To put this another way: the country needs an estimated 24,000 additional health workers simply to reach the minimum threshold recommended by international standards. Nurse and midwife densities currently sit below four per 10,000 people, against a WHO-recommended 23. There are only 429 midwives in the entire country, according to UNFPA data: one midwife for every 1,000 live births, in a country where childbirth remains one of the most dangerous things a woman can do.

The brain drain is not new. Research commissioned by the Heritage Institute for Policy Studies and City University of Mogadishu traces the departure of medical professionals back to the late 1980s, when rising instability pushed the first wave out of the country. By 1990, most specialists had already left. The civil war then destroyed what remained: the Faculty of Medicine was looted, staff and students fled. When the dust settled, rebuilding had to start from almost nothing.

There are signs of recovery. The number of medical schools in Somalia has grown from just one in 1991 to more than 25 by 2024, according to a study published in BMC Medical Education. Young Somalis are entering medicine with genuine motivation: driven, researchers found, by personal ambition, social purpose and a deep sense of duty. But the institutions training them are largely unregulated, curricula are inconsistent, and graduates are entering a system that cannot absorb them fairly. Focus group discussions with young physicians, cited in the same study, revealed that employment in both public and private sectors often depends on personal connections rather than merit. Qualified professionals are being pushed out before they even begin.

The Financing Problem: A Budget That Does Not Match the Burden

In 2023, Somalia received $4.5 billion in debt relief from the IMF and the World Bank under the Highly Indebted Poor Countries Initiative: one of the most significant economic developments the country had seen in decades. The expectation, built into the terms of that relief, was that freed resources would flow toward poverty reduction and essential public services, including health. What happened instead was a reduction. Somalia's health budget fell from 8.5 percent of the national budget in 2023 to 4.8 percent in 2024, even as the overall budget grew by roughly 10 percent. Amnesty International described this plainly as a betrayal.

The gap between what is allocated and what is actually spent makes the picture darker still. Somalia's own budget records show that in 2022, only 1.3 percent of the overall budget was actually spent on health, against an allocation of 10.6 percent. In 2023, 8.5 percent was allocated and 7 percent spent. Transparency International has flagged corruption as a likely contributing factor in this persistent variance: money that was supposed to reach clinics and hospitals simply did not arrive.

Into this gap, the private sector has stepped: but not in a way that serves everyone. Research from DT Global estimates that the private sector now accounts for around 60 percent of total health expenditure in Somalia. It is thriving in urban centres, offering better-equipped facilities and more experienced staff to those who can pay. But it is fragmented, largely unregulated, and almost entirely absent in rural areas. Nearly half of all health spending still comes from international donors, and most public services are delivered free of charge through NGOs and UN agencies. As DT Global's own analysis notes, this is not a system: it is a patchwork held together by external goodwill, and it is fragile and unsustainable.

The consequence falls hardest on the poor. With public services underfunded and private care out of reach, most Somalis cover healthcare costs out of their own pockets: in a country where, according to government data cited in a 2024 report by the Swedish Expert Group for Aid Studies, around 69 percent of the population lives on less than $1.90 a day.

Governance and the Federal Gap: Too Many Layers, Too Little Coordination

Somalia's adoption of a federal system brought new possibilities for decentralised governance. It also created new complications for healthcare delivery. The Federal Government of Somalia, its member states and regional administrations all share responsibility for health: but the coordination between these tiers, according to the 2024 Frontiers in Public Health study, remains deeply inconsistent. Activities are sometimes endorsed at the federal level without proper communication to the state level. Many donors and partners still operate outside the country for security reasons, aligning with federal structures while bypassing the regional ones that deliver care on the ground.

The private sector, which dominates the system, operates largely in a regulatory vacuum. There is no cohesive framework through which national authorities can oversee private providers, set standards or ensure equitable distribution of services. The Essential Package of Health Services, which the Ministry of Health has been working to revise and implement with partners including WHO, UNICEF and UNFPA, represents a genuine effort at coordination: but implementation remains uneven, particularly in regions with active security challenges.

Somalia scores 31 out of 100 on International Health Regulations compliance, according to WHO assessments: indicating weak preparedness and emergency response capacity. In early 2024, a cholera outbreak resulted in more than 10,000 cases and 120 deaths, according to a 2025 study in Public Health Challenges. Somalia also ranks among the top ten countries in the world for multidrug-resistant tuberculosis, with approximately 246 TB cases per 100,000 people recorded in 2023. These are not only health statistics. They are governance failures made visible.

What Reform Actually Requires: A Veynuus Perspective

The following reflects Veynuus's analysis based on our work in the region and the evidence reviewed. None of this is insurmountable: and that matters to say plainly, because the weight of these challenges can make it feel otherwise. But reform that actually changes outcomes requires more than strategic plans and good intentions. It requires political will, sustained investment and an honest reckoning with what has not worked.

The workforce crisis demands an integrated response. This means not just training more doctors and nurses: the number of medical schools is already growing: but regulating training institutions so that graduates are actually prepared for practice, creating fair and transparent employment pathways, and building retention incentives that give qualified professionals a reason to stay. Somalia's diaspora is an underused resource of enormous value. Many Somali doctors and health professionals living abroad have expressed willingness to return or contribute, as noted in analysis from Hiiraan Online. With structured engagement and the right incentives, the diaspora could become a critical bridge between international expertise and local need.

The financing gap cannot be closed by donors alone, and it should not be. Somalia needs a health budget that matches its health burden: and the allocation needs to be tracked, published and enforced. The variance between what is budgeted and what is spent is not a technical problem. It is a governance one, and it requires accountability mechanisms with real consequences. Military spending currently stands at 24 percent of the national budget, according to Amnesty International. The security of a country and the health of its people are not competing priorities: but the balance between them deserves honest public discussion.

The private sector, which is not going away, needs to be brought into a regulatory framework rather than left to operate outside one. Public-private partnerships, done well, could extend quality care to underserved areas and channel private investment into primary health infrastructure. Done poorly, they deepen inequity. The difference lies in whether the government has the capacity and the will to set the terms.

Finally, community-level primary care is where the most lives can be saved at the lowest cost. Reaching pregnant women before they are in crisis, vaccinating children before outbreaks take hold, training community health workers to serve as the first line of response in areas no doctor will reach for years: these are not glamorous interventions. They are the ones that work. Somalia is among the top three countries globally with the highest number of unvaccinated children, with 1.5 million children under five having never received any vaccination at all, according to the 2024 rebuilding report from the Swedish Expert Group for Aid Studies. That is a solvable problem. It requires logistics, funding and coordination: not a breakthrough.

Kalimow Mohamed Nur eventually got his sons to hospital. They received care. That outcome was not guaranteed: it depended on MSF's presence in Baidoa, on a regional hospital that international support had kept functioning, and on the determination of one family to find a way through. A health system worth having should not require that kind of determination just to survive. It should be there when people need it, regardless of where they live or what they can afford.

That is the standard Somalia deserves to be held to. And it is the standard that those with the power to shape this sector must now commit to meeting.

*Editorial note: This article is an opinion and analysis piece written from Veynuus's perspective. It draws on publicly available research and reports from international organisations including MSF, WHO, UNICEF, UNFPA, Amnesty International, the IMF, the World Bank, Transparency International, Frontiers in Public Health, BMC Medical Education, DT Global, the Heritage Institute for Policy Studies, the Swedish Expert Group for Aid Studies and others. All figures and case references are attributed to their original sources. Veynuus has not conducted original fieldwork for this piece.*