Issue. No 702

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