Building resilient primary health care in somalia: integrating noncommunicable disease and mental health interventions for universal health coverage amidst fragility-a health systems analysis and prospective economic review.

backgroundSomalia's health system remains severely fragile, characterized by a critically low Universal Health Coverage Service Coverage Index (UHC-SCI) of 25 and an acute shortage of health workers (0.11 clinicians per 1,000 population). These structural weaknesses coincide with a growing dual burden of noncommunicable diseases (NCDs), responsible for approximately 42% of total mortality, and widespread mental health disorders with available regional studies suggesting a substantial but incompletely quantified burden of common mental disorders. This study evaluates the health system requirements, financing needs, and policy frameworks necessary for integrating NCD and mental health services into primary health care (PHC) to advance universal health coverage (UHC) in Somalia.

methodsWe conducted a mixed-methods health systems analysis and prospective economic review using a targeted evidence synthesis approach informed by PRISMA-adapted reporting principles. Data were synthesized from the Essential Package of Health Services (EPHS) 2020 Strategic Plan, Global Burden of Disease (GBD) 2019 estimates, and 2024 National Health Accounts (NHA). The One Health Tool (OHT) was applied using a deterministic bottom-up costing approach to estimate the resources required to achieve 80% service coverage by 2030. The model incorporated a 10% drug wastage assumption and a 3% discount rate.

resultsThe analysis identified major structural financing and service delivery gaps within Somalia's PHC system. Out-of-pocket expenditure remains critically high at 46.1%, exceeding the WHO threshold for catastrophic health spending. Economic projections indicate substantial long-term investment requirements for progressive PHC expansion and chronic care integration, with medicines and supplies representing the largest cost driver due to the long-term demands of chronic care.

conclusionsIntegrating NCD and mental health services into Somalia's PHC platform is technically feasible and represents a critical strategy for strengthening health system resilience and accelerating progress toward UHC. Economic projections indicate that achieving the national 80% coverage target will require approximately US$3.1 billion by 2030. The OHT-based projections provide an evidence-informed roadmap for sustainable health financing, workforce restructuring, and chronic care delivery in fragile settings.

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