Equity in health funding: an analysis of the essential package of health services (EPHS) in Somalia (2021–2026)

Somalia’s Essential Package of Health Services (EPHS) provides basic health interventions, especially for maternal and child health. However, its success depends on equitable funding across regions and programs. Somalia’s health financing is dominated by external donors and high household out-of-pocket spending, raising concerns that resources may not align with population needs. We analyzed EPHS funding from 2021–2026 by program area and by region to assess whether allocation reflected health needs and equity goals. Over 90% of EPHS funds during this period came from international donors, while the government contributed less than 10%. More than half of the funding supported reproductive, maternal, and newborn health, whereas other essential services—child health, communicable disease control, first aid and emergency care, and treatment of common illnesses—each received only about 5–15%. Programs for chronic diseases and mental health received negligible funding (combined 5%). Per capita funding varied greatly by region: relatively stable regions (Somaliland, Puntland, and Banadir/Mogadishu) had about two to three times more funding per person than conflict-affected states (e.g., Southwest and Hirshabelle). Some of the least-funded regions also had the worst health outcomes, including the highest under-five mortality rates. We observed an inverse correlation between per capita funding and under-five mortality across regions, indicating that higher-need areas were often under-resourced. Qualitative interviews with policymakers and donors reinforced that funding tends to flow to more secure, accessible regions, leaving insecure communities underserved. These findings reveal notable inequities in how health funds are distributed in Somalia. Without deliberate corrective measures, the current funding patterns may perpetuate or worsen health disparities. Policymakers and partners should strengthen coordination and adopt needs-based allocation strategies to ensure that Somalia’s limited health resources are distributed more equitably across both regions and health programs, advancing progress toward universal health coverage. Somalia’s health plan (the EPHS) aims to provide basic services fairly to all people, especially mothers and children. We studied where the money for the EPHS comes from and how it is spent from 2021 to 2026. We found that: We recommend that Somali authorities and donors work together to spread funds more evenly. By investing more in underserved regions and services (like clinics for rural areas and care for chronic diseases), Somalia can move closer to fair health coverage for everyone.