Inequality and Underfunding in Somalia's Healthcare Sector
Last week, David Ngira from Amnesty International East and Southern Africa penned a damning article highlighting the "ailing" state of Somalia's healthcare sector. In particular, Ngira emphasised the federal government's severe neglect of the health budget—despite the major debt relief package that was secured from the International Monetary Fund and World Bank in late 2023. Chronic underfunding, systemic corruption, and sustained instability have resulted in massive discrepancies in healthcare access and quality between Somalia's regions.
As a result of the political and economic turmoil of the 1980s and particularly the total collapse of state-run social services in 1991, healthcare provision in Somalia was left with a threadbare array of largely unreliable private operators. Prior to this, there were several notable hospitals and medical research departments in Somalia, including the National Academy of Science and Arts in Mogadishu. The Somali Agency for Import of Pharmaceutical and Allied Products was responsible for overseeing the import of quality medicines. This entirely collapsed in 1991-- hospitals and pharmacies were gutted, doctors and medics were displaced, and the importation of medicines dried up. Easily preventable diseases such as cholera and malaria spread widely, while those living with illnesses such as cancer and HIV/AIDS went entirely without treatment. It is difficult to estimate the number of Somalis that have died because of the collapse of the healthcare system, but it is sure to run into the hundreds of thousands. The cyclical humanitarian crises that have consumed Somalia in the three decades since have left enormous consequences for those who experienced severe malnutrition as young children, such as stunted growth. Today, Somalia routinely ranks as one of the worst countries in the world for health outcomes, with exceptionally high levels of child and maternal mortality and low immunisation rates.
While a central government has been re-established, a single government hospital was supposed to serve Mogadishu's entire population in 2022, forcing most residents to seek care at private clinics or hospitals where fees are often prohibitively high. Following Al-Shabaab's deadly attack on the Syl Hotel in Mogadishu in March 2024 that left over a dozen people dead, many of the injured were dispatched to Turkey for medical treatment. The fact that the capital seemingly did not have the medical capacity to treat gunshot wounds and broken bones after 30 years of near-incessant conflict is staggering. More broadly, there remains a severe shortage of healthcare workers, with only four nurses, midwives, and doctors available per 10,000 people in Somalia, leaving a gaping deficit. This deficit is particularly apparent in remote rural areas, where access to healthcare workers is nigh-impossible for communities unable to travel to major urban centres due to insecurity or poverty.
In the absence of government support, social safety nets in Somalia are primarily provided by extended families and clans and are supplemented by remittances from Somalis abroad. However, these funds are often insufficient to pay for unforeseen medical bills, which can result in families accruing significant debt. These health inequalities appear particularly stark when the Somali elite can jet off to Nairobi, Dubai or Europe for treatment, while most Somalis have to navigate issues such as the sale of counterfeit, expired, and sub-standard medicines by unlicensed clinics and pharmacies.
With their families able to afford better treatment, it is perhaps little wonder that successive federal administrations have neglected the health budget and that vast sums continue to be embezzled from the system. In one galling episode in 2020, a regional court in Mogadishu sentenced Abdullahi Hashi Ali, then director general of the Health Ministry, and three other senior officials to up to 18 years in prison for embezzling official funds donated to curb the coronavirus outbreak, among other offences. In his article, Ngira further highlighted the immense discrepancies between the funds allocated to health on paper and actual federal expenditure in recent years. For instance, in 2022, just 1.3% of the overall budget was spent on health, despite an allocation of 10.6%. Considering that the vast majority of Somalia's federal budget is derived from the largesse of the international community, the scale of corruption and misappropriation is even more outrageous.
Still, the situation somewhat improved in 2023, with 7% of the 8.5% allocated funds spent on the country's healthcare system. It was particularly disappointing then when it emerged that, despite the successful completion of the Highly Indebted Poor Countries Initiative (HIPC) in late 2023, the health budget had been slashed to just 4.8% for 2024. Part of the HIPC agreement was contingent on Somalia's federal government agreeing to prioritise spending on developing services such as healthcare. Moreover, the reduction comes despite an overall budgetary increase of around 10%, a fall in debt repayments, and a steep drop in Somalia's debt-to-GDP ratio from 64% to 6%. The see-sawing of the budget further undermines any health system development, and while the occasional official is publicly prosecuted for corruption, the issue is systemic.
Somalia's corrosive instability continues to impede healthcare access and development. The impact ranges from the prioritisation of the military in federal budgets to improvised explosive devices limiting road travel to the targeting of international humanitarian professionals by Al-Shabaab and the Islamic State in Somalia (ISS). In 2023, there were several grim instances of healthcare workers being targeted by extremists and others, including the murder of a World Health Organisation staff member by militants during the attack on the Pearl Beach Hotel and Restaurant and the kidnapping of 5 health workers in Hiiraan. In June 2024, two major private hospitals in the coastal city of Bosasso in Puntland were also forced to shut down due to increased extortion demands by the ISS. To date, they remain closed.
The government should not overlook the need for adequate health funding amidst their efforts against Al-Shabaab nor allow ministers and officials to use the health budget as their personal accounts. Several less costly programmes could be implemented to support healthcare, such as basic medical education and awareness raising for the general public, crucial in areas without a permanent medical presence. Tighter regulations and enforcement surrounding the import of drugs, predominantly from Turkey, India, and China, would help regularise the numerous pharmacies across the country. Above all, the federal government should maintain its financial and international commitments to spend a significant proportion of its budget on healthcare.
By the Somali Wire team
Gain unlimited access to all our Editorials. Unlock Full Access to Our Expert Editorials — Trusted Insights, Unlimited Reading.
Create your Sahan account LoginUnlock lifetime access to all our Premium editorial content
With all eyes trained on the Strait of Hormuz blockades and their geopolitical convulsions, discussions and concerns, too, have risen about the perils of other globalised chokepoints, not least the Bab al-Mandab. The threats to the stability of the Bab al-Mandab, the Gulf of Aden, and the Red Sea may not arise principally from the escalatory logic that the US, Iran, and Israel have been locked in, but the threats posed from collapse and contested sovereignty offer little relief. Off Somalia's northern coastline in particular, it is transnational criminal networks — expressed in smuggling, piracy, and, less visibly but no less consequentially, illegal, unreported, and unregulated (IUU) fishing — that define the character of offshore insecurity. It is this last phenomenon that provides the foundation on which much of Somalia's maritime disorder is built, and which remains the most consistently neglected.
In the past months, a number of unsettling images and videos have emerged from the Russian frontlines in the Ukraine war. Within the horrors of the grinding "kill zone," where kamikaze drones strafe the sky for any signs of movement, yet another concerning dimension has emerged—the use of African recruits by Moscow in the conflict, often under false pretences. Particularly drawn from Kenya, many reportedly believed they were signing contracts to work as drivers or security guards, only to be shipped to the front lines upon arrival. Such activities are illustrative of several issues, including Russia's relationship with countries in the Horn of Africa, one shaped more by opportunistic realpolitik than genuine partnership.
Villa Somalia's triumph in Baidoa may yet turn to ashes. Since the ousting of wary friend-turned-foe, Abdiaziz Laftagareen, in late March, the federal government has ploughed ahead with preparations for state- and district-level elections in South West. Nominally scheduled for next week, President Hassan Sheikh Mohamud has chosen to reward his stalwart parliamentary ally, Aden Madoobe from the Rahanweyne/Hadaamo, with the regional presidency after some vacillation, naming him the sole Justice and Solidarity Party (JSP) candidate
Another showdown over Tigray's political architecture is unfolding, with the future of the Tigray Interim Administration (TIA) once again at stake. For much of this year, fears of renewed war have loomed over Ethiopia's northernmost region, with the federal government mobilising substantial forces to the edges of Tigray.
In Act III, Scene I of William Shakespeare's tragedy Coriolanus, the tribune Sicinius addresses the gathered representatives and, rejecting the disdain the titular character displays towards plebeians, defends them, stating, "What is the city but the people?" Capturing the struggle between the elite and the masses of ancient Rome, the line has remained politically resonant for centuries--emphasising that a city, democracy, and state rely on the people, not just their leader. Or perhaps, not just its buildings. It is a lesson missed by Villa Somalia, though, with the twilight weeks of President Hassan Sheikh Mohamud's term in office — at least, constitutionally — dominated by the government's twin campaigns in the capital: land clearances and the militarisation of Mogadishu.
On Tuesday, 14 April, the four-year term of Somalia's federal parliament ended, or rather, it didn't. Villa Somalia's (un)constitutional coup of a year-long term extension for the parliament and president in March remains in effect, leaving the institution in a kind of lingering zombie statehood. It is perhaps a fitting denouement for the 11th parliament, whose degeneration has been so thorough that its formal expiration means little in practice.
Yesterday, 15 April, marked three years of brutal, grinding warfare between the Sudanese army and the Rapid Support Forces (RSF). Wholly neglected by a fading international community, many grim landmarks have been passed; another genocide in Darfur, the weaponisation of rape and starvation, another famine, or the desecration of Khartoum, El Fasher, and other major cities. And with no ceasefire or settlement in sight, the war has continued to swell, drawing in each neighbouring African country as tussling Middle Eastern powers grapple for the upper hand-- leaving Sudan in tatters.
As global energy markets reel from the partial shutdown of the Strait of Hormuz and war insurance premiums skyrocket by nearly 4,000%, an unlikely maritime security provider is emerging as a critical stabiliser in one of the world's most vital shipping corridors. The Somaliland Coast Guard, operating from the port city of Berbera, has quietly begun providing maritime escort services, seeking to reduce shipping insurance costs—and consequently, the price of commodities and energy for consumers across the Horn of Africa and beyond.
Most nights in a number of dimly lit bars in Addis Ababa, one can hear a vibraphone hum over a syncopated bassline. The sprightly rhythm is unmistakably jazz, but the scales are Ethiopian; pentatonic, looping and melodic. Five decades after its pioneering by visionary musician Mulatu Astatke, Ethio-jazz remains in full swing, with its renaissance from the late 1990s persevering despite tough political and cultural conditions.