From Outbreak Response to System Resilience: Tropical Medicine in Somalia
Why specialists in tropical medicine and infectious diseases are central to Somalia’s health security, and how to build the workforce the country needs.
Key points
- Leadership, governance and stewardship are different jobs, and a fragile system needs all three.
- Accountability runs in three directions: upward, downward and horizontal.
- A health system can be privately delivered but publicly governed.
- Reforms fail when they are technically correct but politically and institutionally unrealistic.
Start with the system, not the symptom
Why did the patient arrive late? Why was the referral delayed? Why was the medicine unavailable? Why did the household pay out of pocket? Why did the data system fail to alert managers in advance? Questions like these move a clinician from treating a case to diagnosing a system.
When a health centre reports recurring medicine shortages, the useful question is not only who failed to order. It is how budgeting, procurement, warehousing, forecasting, transport, data reporting, provider incentives and governance combined to produce the shortage.
Three different jobs
- Leadership mobilises people toward a shared vision.
- Governance defines the formal and informal rules through which decisions are made, authority is exercised and resources are controlled.
- Stewardship is the ethical and strategic responsibility of the state to protect the health of the population, especially the poor, vulnerable and marginalised.
Strong stewardship does not require the state to provide every service directly. It does require the state to set rules, coordinate actors, regulate quality, protect equity and hold institutions accountable.
Accountability is not a slogan; it is an architecture.
Three directions of accountability
Upward accountability connects facilities and implementing partners to ministries and funders. Downward accountability connects providers and authorities to citizens and communities. Horizontal accountability connects professional councils, audit institutions, regulators, courts, parliament, civil society and peer-review bodies. In fragile contexts all three are needed, because no single vertical chain is strong enough to govern the system alone.
Governing a mixed system
Somalia’s large private and informal market should not be seen only as a problem. It can be a significant asset when governed well. The policy task is to turn an unregulated market into a regulated partner for Universal Health Coverage through licensing, accreditation, price transparency, data reporting, medicine quality assurance, complaint mechanisms, referral protocols and selective contracting.
A health system can be privately delivered but publicly governed.
Support or strengthening?
System support fills urgent needs quickly; system strengthening improves the capacity, relationships and incentives that drive performance. Buying solar refrigerators for vaccines is support. A cold chain with a maintenance budget, trained staff, dashboards and accountability routines is strengthening. Managers should be clear about which one is being funded, and what will remain when the project ends.
Leading reform
Health systems reforms fail when they are technically correct but politically and institutionally unrealistic. Leaders therefore combine evidence with negotiation, communication, sequencing, coalition building and adaptive learning. In fragile settings reform is rarely linear: managers pilot, learn, adjust and institutionalise reforms through credible routines.
A reform dashboard for Somalia
| Pillar | 0–12 months | 1–3 years | Long-term goal |
|---|---|---|---|
| Governance | Clarify coordination architecture and decision rights | Performance compacts across federal, state and district levels | Legally coherent stewardship and regulation |
| PHC and EPHS | Map coverage gaps and priority districts | Scale integrated EPHS with community platforms | Universal PHC access with reliable referral |
| Financing | Map financing flows and out-of-pocket burden | Pilot pooled purchasing for priority services | Sustainable domestic financing and financial protection |
| Workforce | Update the HRH registry and deployment map | Rural retention package and task-sharing policy | An equitable, competent and motivated workforce |
| Quality and regulation | Minimum service standards and supervision tools | Accreditation for public and private facilities | A culture of continuous quality improvement |
| Information | Data quality reviews and a private-provider reporting plan | District dashboards linked to decisions | One national HIS used for learning and accountability |
Adapted from Health Systems Management and Reform: Governance, Financing, Service Delivery, and Resilience in Somalia, the MSc Health Systems Management handbook by Dr Abdulrazaq Yusuf Ahmed, Benadir University School of Postgraduate Studies.