Strengthening health system resilience in Somalia: The role of community health workers.

Objectives: To synthesize global evidence and Somalia-specific reports on the role of community health workers (CHWs) in addressing health vulnerabilities within fragile and conflict-affected settings, and to argue that CHWs represent a primary care response essential for strengthening health system resilience in Somalia. Study design: Narrative synthesis of published literature and selected reports. Methods: A targeted search of PubMed/MEDLINE, Scopus, Google Scholar, and institutional repositories (WHO EMRO, World Bank, UNICEF Somalia) was conducted using combinations of terms including ("community health worker" OR "CHW" OR "female health worker") AND ("Somalia" OR "fragile setting" OR "conflict-affected") AND ("health system resilience" OR "primary health care" OR "maternal health" OR "disease surveillance"). Peer-reviewed articles and institutional reports published in English were eligible for inclusion. Sources were excluded if they lacked Somalia-specific data or empirical grounding. As a narrative review, the search was purposive rather than exhaustive, consistent with the interpretive synthesis approach. Two authors independently screened titles and abstracts, with full-text review of potentially eligible sources. Key findings were extracted regarding intervention design, outcomes, and implementation barriers. The synthesis was developed iteratively: all authors reviewed the evidence summary and interpretive framework, and consensus on conclusions was achieved through multiple rounds of written revision and discussion. Results: Somalia faces one of the world's most acute health workforce shortages, with fewer than 0.4 doctors, nurses, and midwives per 10,000 populations-well below the WHO minimum threshold of 23 per 10,000-and over 5.4 million people in urgent need of health services. Global evidence from 55 studies across 19 conflict-affected settings demonstrates that CHW-delivered interventions effectively circumvent access barriers and strengthen disease detection, care-seeking, and treatment adherence. In Somalia, community-based maternal and newborn care programs in rural Galmudug, delivered through 34 CHWs serving 1165 women over 24 months, achieved 88% enrollment coverage, 94% average competency scores, and strong acceptability among participants. CHWs also contributed to COVID-19 surveillance, identifying approximately one-third of suspected cases with higher positivity rates than facility-based surveillance. Mental health represents a substantial and neglected component of Somalia's disease burden, with an estimated one in three Somalis affected by some form of psychological disorder, yet 80-90% lack access to care. CHWs have demonstrated potential to deliver effective mental health care for conflict-affected populations, including PTSD. However, current programs face inconsistent integration into national systems, variable supervision, fragmented external support, and sustainability concerns amid 95% donor-dependent health financing. The Community Health Strategy 2025-2029 represents a landmark policy shift toward professionalizing and integrating the CHW workforce under government leadership. Conclusions: CHWs are not merely supplementary actors but represent a primary care response essential for addressing Somalia's health vulnerabilities. Deliberate investment in CHW workforce development-through formal recognition within the Essential Package of Health Services, standardized training and certification, sustainable financing, improved supervision linked to district health systems, and strengthened community engagement-is critical to strengthening primary health care and build health system resilience. As Somalia implements its Community Health Strategy, sustained investment, government ownership, and international partnerships will be vital to translating policy into impact for every Somali family.