Operationalizing health service delivery in Somalia: a health systems policy analysis toward universal health coverage

Somalia’s health system operates under protracted fragility, recurrent climate shocks, displacement, and a mixed public, private, and humanitarian delivery landscape. This study examined how health service delivery can be operationalized while advancing universal health coverage (UHC). We conducted a document-based health systems policy analysis of peer-reviewed literature, official policy documents, technical reports, and program records published from January 2000 to January 2026. Sources were identified through PubMed, Google Scholar, official Federal Ministry of Health sources, and multilateral and humanitarian repositories. Sixty-one sources met the eligibility and credibility criteria. Walt and Gilson’s policy-analysis framework informed interpretation of context, actors, content, and process; WHO health-system building blocks provided the primary coding framework. National policies provide a platform for primary health care and UHC, but implementation occurs across fragmented authority and a large non-state sector. The evidence indicated high household payment exposure, uneven regulatory and reporting capacity, workforce and medicine-supply constraints, and marked geographic and socioeconomic barriers. Documented delivery assets included the Essential Package of Health Services, community and mobile platforms, and routine information systems, although their institutionalization was uneven. The analysis supports a sequenced, governance-sensitive approach: agree a minimum accountability floor, protect a core primary care package, stabilize frontline inputs, and use data for supervision and learning. Subsequent purchasing and provider-integration reforms should be piloted only where roles, financing, verification, and implementation capacity are in place.