Issue No. 835

 Somalia's Fractured Healthcare Economy

Since the collapse of the Somali state in the 1990s, the country's private sector has played a particularly prominent role in service delivery, flourishing in the cracks left by the absence of a central government. In this space of the ungoverned economy, those providing essential utilities -- such as healthcare -- were assumed by businesses and economic cartels, which have reaped immense profits in turn amid the vacuum. However, in the years since, as the state-building process has gradually attempted to deliver or centralise such services, the incestuous relationships between business cartels and rent-seeking politicians have persisted. And in the meantime, the fractured and uneven nature of healthcare providers in Somalia continues to pose severe dangers to the population. 

Today, the patchwork nature of the healthcare services has created a vastly unequal system, accentuated by the influx of millions of dollars into healthcare and humanitarian development in the government-controlled parts of the country. Without a functioning state in the 1990s, attempts to monopolise and hijack humanitarian aid and non-governmental organisation work in the following years soared alongside the seizure of rent-generating infrastructure. And while formal government-run hospitals may have collapsed, pharmacies-- that continue to deliver the majority of healthcare across Somalia-- sprang up in their place. These have played essential roles in providing healthcare services to Somalis across the country, even if these efforts have often been haphazard due to the illicit importation of substandard medicines, among other issues. Formal public health infrastructure in Somalia is skeletal, and largely supported by international organisations such as UNICEF, the World Health Organisation, and Médecins Sans Frontières. And even while the best hospitals are overwhelmingly concentrated in Mogadishu, the political elite and their families routinely travel to Nairobi, Dubai, and further afield for medical treatment. 

On the other end of the spectrum from the premier hospitals and pharmacies within Halane, there are the small, informal drug shops dotted across rural Somalia that double up as 'clinics.' Consequently, there are also glaring absences in the type and quality of treatment across the country, such as regarding therapy for cancers and those requiring kidney dialysis treatments, that further mirror the socio-economic inequalities that pervade Somalia. The scarcity of treatment for cancer or kidney ailments is partly due to socio-economic disparities, but it also reflects the absence of public investment in healthcare and the weakness of the state. In theory, governments should be able to afford high-value equipment for public hospitals, but low budgets for healthcare have left expensive treatments in the hands of the private sector. And due to its unregulated framework and porous borders, the country has long been the dumping ground for international pharmaceutical companies to rid themselves of expired medications that are bought up by insatiable merchants. Issues of self-administering drugs, whether or not there is such a need, combined with minimal prescription oversight, are driving antibiotic and antimicrobial resistance.

Many have understandably praised the entrepreneurial nature of the private sector within Somalia. But one of the enduring questions is how to regulate and standardise the healthcare industry across the administrations that control its various constituencies. There are few incentives, for instance, for companies that operate near-monopolies over essential services such as water and electricity in major cities to improve upon their products or allow competition to flourish-- nor do they have to, with corruption able to choke off genuine free market economics. While perhaps not tied to marauding militias, the rent-seeking business cartels linked to dominant clans endure to this day and continue to be enabled by collusion with political actors. In particular, many of the most affluent within Somalia's industries-- especially relating to telecommunications and healthcare-- are intimately tied to Al-I'tisaam, the influential and transnational Salafist organisation. 

Despite the federal government's actual authority being largely confined to Mogadishu and a few other urban centres, it has nevertheless continued to attempt to centralise and monopolise authority over the healthcare sector, amongst numerous other services. This is intimately tied to a reductionist and rent-seeking interpretation of sovereignty, with the delivery of services to all citizens relegated below its own self-interests. Villa Somalia should either lead, follow, or get out of the way in relation to healthcare. But not only is it incapable of providing it countrywide, the federal government also continues to stifle attempts by anyone else to do so.

Part of this further stems from a lack of clear demarcation of roles and responsibilities for service delivery within the Provisional Constitution, as well as the enduring disputes about where the economic burden should fall. However, the federal government is nominally supposed to play several roles within the healthcare sector: serving as a regulatory body, providing technical expertise and support, and delivering budgetary support to the devolved administrations responsible for healthcare. But the government's sporadic and half-hearted gestures towards regulation appear intended more to appease the international community than to genuinely tackle the ingrained issue. The Ministry of Health and Human Services is the primary body tasked with this, and recent developments include the establishment of the National Health Professionals Council (NHPC) in 2020 and the Interim National Medicines Regulatory Authority (INMRA) in 2023. Both are intended to standardise healthcare and the importing of medicines. However, with Puntland and Jubaland absent from the federation, and humanitarian and development assistance continuing to be weaponised by Villa Somalia, such legislation matters little when considered in these political and economic realities. 

The allocation of 'powers' in security, natural resource exploitation and taxation, et al., may be legitimate domains for political contestations between the federal and regional administrations-- pending completion of the constitution and federal architecture-- but there is little justification for such competition over 'responsibilities' like health and education. And while such debates over policy may be fair game, resource monopolisation that hurts the health of the Somali people is not.

The Somali Wire Team

Please note that from 17 – 19 June 2025, our publication will temporarily exclude the news summaries section and feature only editorials due to our staff retreat. Regular publishing format will resume on 20 June.