Challenges in cancer diagnosis in Somalia through 35 years of instability (1991–2025): a pathologist’s experience

Somalia’s long-term instability since 1991 has severely disrupted pathology services, the cornerstone of cancer diagnosis, resulting in delayed and inaccurate diagnoses. This study provides a firsthand account of the evolution, current capacity, and systemic challenges of cancer diagnostic pathology in Somalia over 35 years of instability. A convergent mixed-methods study was undertaken to evaluate limitations of cancer diagnostic pathology services in south Somalia between 1991 and 2025. The quantitative component included all nine operational histopathology laboratories and assessed laboratory infrastructure, workforce, workload, and diagnostic capacity using standardised data abstraction from institutional records. The qualitative component consisted of semi-structured interviews with 14 practising pathologists exploring barriers, diagnostic limitations, and priorities for strengthening pathology services. Quantitative and qualitative findings were analysed independently and integrated during interpretation. Nine operational pathology laboratories employing 14 practising pathologists were identified, collectively processing an estimated 25,000–30,000 histopathology specimens annually, increasing the number of operational laboratories from one to nine between 2015 and 2025. Pathology services expanded substantially following the establishment of the Mogadishu Somali-Türkiye Training and Research Hospital (MSTTRH) in 2015. However, immunohistochemistry (IHC) was available in only one laboratory, while frozen section and molecular diagnostic services were unavailable nationwide. Qualitative analysis identified four major themes: inadequate laboratory infrastructure and recurrent reagent shortage; workforce and specialist training limitations; restricted access to advanced diagnostic technologies; and the need for improved quality assurance, multidisciplinary collaboration, and national coordination. In 2024, the Banadir region, Somalia, established its first histopathology-based cancer registry, providing the foundation for systematic national cancer surveillance. Somalia has made substantial progress in rebuilding cancer diagnostic pathology services despite decades of conflict. However, major investments in advanced diagnostics, workforce development, laboratory quality systems, and cancer surveillance remain essential to achieve equitable, high-quality cancer diagnosis. The findings provide evidence to inform national cancer control planning and offer insights relevant to strengthening pathology services in other resource-constrained and conflict-affected settings.