Building Resilient Primary Health Care in Somalia: Integrating Non-Communicable Disease and Mental Health Interventions for Universal Health Coverage amidst Fragility

Building Resilient Primary Health Care in Somalia: Integrating Non-Communicable Disease and Mental Health Interventions for Universal Health Coverage amidst Fragility | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Building Resilient Primary Health Care in Somalia: Integrating Non-Communicable Disease and Mental Health Interventions for Universal Health Coverage amidst Fragility Abdirezak Abdi This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7899632/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Somalia’s health system is defined by extreme, chronic fragility, exemplified by a critically low Universal Health Coverage (UHC) index of 25% and a severe health workforce shortage, with only 0.11 clinicians per 1,000 population . This systemic weakness, a legacy of three decades of conflict and humanitarian crisis, intersects with an accelerating dual burden of Non-Communicable Diseases (NCDs) and Mental Health (MH) disorders. NCDs account for approximately 42% of total mortality , while the pervasive impact of violence and displacement means MH disorders affect an estimated one in three individuals . This manuscript presents a comprehensive health systems analysis and prospective economic projection of Somalia’s strategic shift toward an integrated Primary Health Care (PHC) model designed for resilience in fragile, conflict-affected settings (FCAS). Utilizing the rigorous One Health Tool (OHT) for the EPHS 2020 Implementation Strategic Plan (EPHS-ISP), we model the resource needs required to achieve 80% coverage by 2030. The analysis projects a total investment of US$3.1 billion over the decade. Critically, the economic findings confirm a profound structural transformation: the costs required for continuous chronic care—specifically essential medicines and supplies—will surge to constitute 60% of total implementation costs by 2030 . This finding mandates immediate operationalization of the strategic purchasing model, aggressive, utilization-driven task-sharing leveraging Female Health Workers (FHWs) trained in WHO-PEN/MhGAP protocols, and robust digital health integration for resilient supply chain management. We conclude that sustainable UHC and long-term health security in Somalia rely on institutionalizing chronic care resilience within the core PHC platform, supported by stable domestic financing and rigorous, performance-based governance. Health Policy Health system resilience Universal Health Coverage Non-Communicable diseases mental health primary health care Essential Package of Health Services health financing task-sharing digital health. 1. Introduction 1.1 Background: The Acute Crisis of Chronic Care in FCAS Global public health efforts have historically defaulted to an acute, crisis-driven response in Fragile and Conflict-Affected States (FCAS), prioritizing immediate trauma care and infectious disease control. This approach is now structurally insufficient. Prolonged instability, coupled with global demographic and epidemiological shifts, means that FCAS populations are increasingly susceptible to a chronic disease burden that existing systems are incapable of managing. In Somalia, three decades of civil war, weak governance, and continuous humanitarian shocks have resulted in a system characterized by profound fragility. This environment severely restricts access to continuous, life-long chronic care, including essential medications and mental health support, leading to significantly higher mortality rates among people living with NCDs (PLWNCDs). The inability to maintain the continuity of essential services —a core requirement for NCD and MH management—during periods of shock highlights a critical systemic vulnerability: the lack of health system resilience. The paradigm shift mandated by the EPHS 2020, transitioning from fragmented aid to an integrated PHC platform, is a direct response to this failure, aligning Somalia’s strategy with the global call to integrate health security and long-term PHC resilience in FCV settings. 1.2 Somalia’s Structural Deficits and Dual Burden The structural crisis is evidenced by Somalia's UHC index of only 25% and a health workforce density of only 0.11 clinicians per 1,000 population, contrasting sharply with the WHO target of 2.28 per 1,000. The average life expectancy is approximately 56 years. While the historical burden of communicable diseases (CDs), maternal, neonatal, and nutritional disorders still account for 68.8% of total Disability-Adjusted Life Years (DALYs), the nation is undergoing a rapid epidemiological transition toward chronic illness. Non-Communicable diseases (NCDs) are responsible for approximately 42% of total mortality in 2019. This burden is inextricably linked to a massive mental health crisis, with depression and anxiety estimated to affect one in three individuals —a prevalence significantly exceeding global averages. Mental disorders rank thirteenth among the top health problems causing long-term disability, as measured by Years Lived with Disability (YLDs). The immediate necessity for comprehensive service expansion and integration is detailed in the baseline health indicators below. Table 1 Somalia's Key Health Indicators and Service Coverage (2006–2020) | Source: Federal Ministry of Health, Global Health Estimates, Somalia UHC Index (Approx. 2020 Baseline) | Location: Somalia. Indicator 2006 2016 2019/2020 (Baseline) Maternal Mortality Ratio (per 100,000 LBs) 1040 865 692 Under-five Mortality Rate (per 1,000 LBs) 170.5 128.4 122 Births Attended by Skilled Personnel (Coverage) N/A N/A 32% Children Fully Immunised (Coverage) N/A N/A 11% UHC Index N/A N/A 25% 1.3 Financial Instability: The Impasse of Out-of-Pocket Payments Low public investment (annual per capita health expenditure of US $ 13) translates directly into a crippling financial burden on citizens. Out-of-Pocket Payments (OOP) constitute a staggering 46% of total health expenditure . This level of catastrophic spending severely restricts access to long-term chronic care, compromising the financial protection pillar of UHC. Financial stability is further undermined by high reliance on fragmented external donor contributions (38% share) and insufficient domestic government expenditure (15% share), leading to a volatile and unsustainable financing environment. The financial structure that necessitates transformation through strategic purchasing is summarized below. Table 2 Health Financing Structure and Barriers (Approx. 2020 Baseline) | Source: Federal Ministry of Health, National Health Accounts (Approx. 2020 Baseline) | Location: Somalia Metric Value Implication for UHC Annual Per Capita Health Expenditure (Total) US $ 13 Critically low compared to regional averages (SSA average $ 204). Out-of-Pocket Payments (OOP) Share 46% Major barrier to access; compromises UHC financial protection pillar. Donor Contribution Share (Off-treasury) 38% High reliance on fragmented, unpredictable external funding. Government Expenditure Share 15% Insufficient domestic commitment for sustainable health system. 1.4 Objectives This study performs a rigorous analysis and quantification of Somalia’s strategic shift to integrate chronic care into its PHC system via the EPHS 2020. The specific objectives are: To evaluate the systemic fragilities and epidemiological drivers (YLD vs. YLL analysis) mandating the integration of NCD and MH services into the core PHC platform. To analyze and elaborate the operational frameworks of the EPHS 2020, focusing on the mandated adoption of WHO-PEN/MhGAP protocols, utilization-driven task-sharing, and digital health as foundations for service resilience. To present and interpret the economic projections from the One Health Tool (OHT) Costing Scenario (2020–2030), specifically quantifying the total investment, the structural cost shift toward chronic supplies, and the projected efficiency gains required to achieve the UHC target. 2. Methods 2.1 Study Design: Health Systems Analysis and Prospective Economic Modeling Review The research employs a robust Health Systems Analysis and Prospective Economic Modeling Review design. This design was chosen as the most appropriate methodology for national policy planning in a complex, data-scarce, and fragile setting like Somalia. Unlike a retrospective systematic review or an empirical study, this design synthesizes qualitative findings on governance and operational challenges with quantitative, forward-looking economic forecasts to create an evidence-based roadmap for systemic transformation. The design’s primary function is to interpret and validate the Federal Government of Somalia’s policy intent—the EPHS 2020—against the actual projected resource requirements and health impact. 2.2 Setting, Scope, and Data Sourcing Rationale 2.2.1 Setting and Scope The study setting is the Federal Republic of Somalia, characterized by a decentralized, federal governance structure that frequently contributes to service fragmentation and coordination challenges. The study scope is national, encompassing all Primary Health Care (PHC) interventions and community-level services defined by the EPHS 2020. The economic modeling component is framed over a ten-year projection period, from baseline (2020) to the UHC target year (2030). The goal of the modeling is to quantify the costs associated with scaling service coverage from the baseline of 25% to the ambitious national UHC target of 80% coverage for the Core EPHS package by 2030. 2.2.2 Data Sources and Rationale Data were synthesized from authoritative sources, explicitly chosen to address the epidemiological, financial, and planning requirements of a resilient health system: Epidemiological Data : Baseline disease burden data, including YLL, YLD, and DALYs, were extracted from the Global Burden of Disease (GBD) estimates for Somalia (2019) . This data source provided the intellectual justification for the NCD/MH integration, demonstrating that chronic disability (YLD) is dominated by NCDs and Mental Health disorders, necessitating a shift away from a sole focus on acute mortality (YLL) (Table 3 ). Health Financing Metrics : Baseline financial data (per capita expenditure, OOP share, government allocation) were sourced from National Health Accounts (NHA) reports and Ministry of Finance budget execution reports (Table 2 ). These data quantify the severity of the financial protection gap and establish the baseline fiscal space that must be expanded. Policy and Operational Documents : The EPHS 2020 and its Implementation Strategic Plan (EPHS-ISP) served as the foundational operational blueprint. These documents provided the qualitative inputs regarding the mandated clinical protocols, task-sharing models, and governance strategies (Table 4, Table 5). 2.3 Economic Modeling Methodology: The One Health Tool (OHT) Application The core quantitative analysis relies on the One Health Tool (OHT) , an internationally standardized software platform used by WHO and partners for national health sector strategic planning and resource forecasting. The OHT is a deterministic model that calculates resource requirements based on target populations, desired service coverage levels, and established unit costs. 2.3.1 Key Modeling Parameters and Inputs The OHT was applied to the EPHS 2020 Costing Scenario using meticulously defined parameters: Target Coverage : The model explicitly scaled the EPHS interventions to reach 80% coverage by 2030 , reflecting the official national UHC commitment. Intervention Integration : The model inputs systematically incorporated the full resource costs of the newly mandated chronic care interventions: the WHO Package of Essential Non-Communicable Disease Interventions (WHO-PEN) and the Mental Health Gap Action Programme (MhGAP) . This integration included the procurement of standardized essential medicines (e.g., insulin, anti-hypertensive, and psychotropic), specialized NCD/MH diagnostics, and the cost of non-physician health worker (NPHW) training modules (MhGAP training). Workforce Costing : The model utilized the utilization-driven staffing model mandated by the EPHS 2020, which links staffing levels to projected patient volume in specific geographic areas. This methodology accurately costed the expanded deployment and supervision of lower-cost resources, such as Female Health Workers (FHWs) , ensuring a rationalized cost for the task-sharing approach. 2.3.2 Cost Components and Analysis Output Total costs were rigorously broken down across five categories to identify the source and trajectory of expenditure (Tables 7 , 8 ): Human Resources (Salaries) : Initial investment in training and salaries for the expanded workforce. Infrastructure : Costs for facility rehabilitation and new builds (e.g., PHUs, Health Centers). Medicines and Supplies : This component captured the entire pharmaceutical load, critically including the continuous supply required for chronic care management (NCDs, MH, and Nutrition). Logistics : Transportation, storage, and distribution costs. In Somalia, this component is disproportionately important due to high insecurity, distance barriers, and the need for resilient, frequent distribution to remote areas (reflected in the projected 10% proportional increase by 2030, Table 8 ). Programme Costs : Management, supportive supervision, and quality assurance overhead. The primary output analyzed was the structural shift in cost composition , specifically the proportional increase of the Medicines and Supplies component, which served as the quantitative evidence of the system's shift toward a chronic care footing. 2.4 Integrated Analytical Frameworks The EPHS 2020 operates as the primary integrated framework, built on the principle of Progressive Realization , dividing services into a mandatory Core Package and a long-term Extended Package . 2.4.1 Clinical Methodology: WHO-PEN and MhGAP Integration The mandated integration of chronic care utilizes two internationally validated clinical methodologies: WHO-PEN : The Package of Essential Non-Communicable Disease Interventions provides a standardized, simplified clinical algorithm for NCD diagnosis and management at the PHC level. The EPHS emphasizes the total cardiovascular risk approach —a cost-effective strategy that targets limited resources (e.g., essential anti-hypertensives) to individuals with the highest calculated absolute risk of a cardiovascular event, maximizing population health impact in a resource-constrained environment. MhGAP : The Mental Health Gap Action Programme provides a framework for task-sharing mental health interventions, using non-specialist health workers (NPHWs and FHWs) to manage priority conditions like depression and anxiety at the community and PHC level. This approach is essential for achieving the required high coverage in Somalia, where specialty services are virtually non-existent. 2.4.2 Governance Methodology: Strategic Purchasing and Accountability To counteract the fragmentation inherent in the federal structure, the methodology analyzed the shift to a strategic governance model (Table 5): Purchaser-Provider Split (PPS) : This model separates the stewardship function (policy-setting, financial risk management, quality control by the MoH) from the delivery function (NGOs and private sector providers). This separation enhances accountability, enabling the MoH to enforce standardized EPHS compliance through contracting. Performance Monitoring : The use of Balanced Score Cards (BSC) and the Performance/Quality Assessment Tool (PQAT) was analyzed as the mechanism for ensuring that contracted providers adhere to EPHS quality standards (including NCD/MH service delivery) and for tracking UHC tracer indicators across FMS, promoting federal-state accountability. 2.5 Ethical Considerations As this analysis is a review and synthesis of secondary policy data (EPHS 2020) and economic projections (OHT), it was exempt from primary human subjects review. The methodological rigor, however, adhered to the highest standards of transparency and accuracy in representing national strategic data and projections. 3. Results 3.1 Burden of Disease Analysis: Justification for Chronic Care Integration The GBD 2019 analysis confirms that the primary challenge is tackling chronic disability (YLD) to improve quality of life and productivity, complementing ongoing efforts to reduce acute mortality (YLL). Table 3 Burden of Disease Analysis: Top 5 Causes of Years of Life Lost (YLL) and Years Lived with Disability (YLD) (2019) | Source: Global Burden of Diseases estimates (2019) | Location: Somalia Top 5 Causes of Years of Life Lost (YLL) Primary Disease Group Top 5 Causes of Years Lived with Disability (YLD) Primary Disease Group Neonatal disorders Maternal/Neonatal Depressive disorders Mental Health/NCD Lower respiratory infections Communicable Disease Low back pain NCD Diarrheal diseases Communicable Disease Gynecological diseases NCD Tuberculosis Communicable Disease Headache disorders NCD Measles Communicable Disease Age related and other Anxiety disorders Mental Health/NCD Source: Global Burden of Diseases estimates (2019) The YLD data confirms that Depressive disorders, Low back pain, Headache disorders, and Anxiety disorders dominate the chronic disability metrics, providing the epidemiological mandate for the systematic integration of WHO-PEN and MhGAP protocols within the EPHS 2020 framework. 3.2 Economic Findings: Total Costs and Structural Cost Transformation 3.2.1 Total Projected Costs and Per Capita Expenditure The OHT model projects a required total investment of US $ 3.1 billion over 2020–2030 to achieve 80% coverage, requiring annual per capita spending to increase from $ 7.4 in 2020 to $ 33.3 by 2030. Table 6 EPHS 2020 Per Capita Costs and Total Projected Cost (US $ Million) | Source: Essential Package of Health Services (EPHS) 2020 One Health Tool (OHT) Costing Scenario (2020–2030) | Location: Somalia) Year Per Capita Cost (US $ ) Grand Total Cost (US $ million) 2020 7.4 104.54 2025 14.1 231.56 2030 33.3 625.47 Total (2020–2030) N/A 3106.03 3.2.2 Composition of Costs: The Definitive Shift to Chronic Care Supplies The most significant finding validating the EPHS 2020 strategy is the structural shift in cost composition: Medicines and Supplies cost is projected to increase from 34% in 2020 to 60% by 2030 . This quantitatively confirms that the long-term cost of the Somali health system will be dominated by the sustained, consumption-based requirements of managing chronic NCD and MH patients. Table 7 Composition of EPHS 2020 Implementation Costs (US $ Million) from 2020 to 2030 | Source: Essential Package of Health Services (EPHS) 2020 One Health Tool (OHT) Costing Scenario (2020–2030) | Location: Somalia Cost Component 2020 (US $ Million) 2030 (US $ Million) Total (2020–2030) (US $ Million) Total Human Resources (Salaries) 48.22 118.58 895.34 Total Infrastructure Cost 10.49 13.04 128.93 Total Medicines and Supplies Cost 36.03 375.06 1594.26 Total Logistics Cost 9.63 117.33 474.22 Total Programme Costs 0.18 1.46 13.29 Grand Total 104.54 625.47 3106.03 Table 8 Percentage Distribution of EPHS Cost Components (Visualizing the Shift) | Source: Essential Package of Health Services (EPHS) 2020 One Health Tool (OHT) Costing Scenario (2020–2030) | Location: Somalia Cost Component 2020 (%) 2030 (%) Change (%) Implication for Chronic Care Human Resources (Salaries) 46% 19% -27% Decreasing relative importance post-initial investment. Medicines and Supplies 34% 60% + 26% Dominant driver by 2030; reflects sustained chronic medication needs. Infrastructure 10% 2% -8% Decreasing relative importance post-initial rehabilitation. Logistics 9% 19% + 10% Increase proportional to drug/supply distribution scale. 3.3 Resource Allocation, Efficiency, and Dominant Cost Drivers 3.3.1 Resource Allocation by Facility Type and Efficiency Gains The decentralized nature of the EPHS is reflected in the allocation, with Health Centres (HCs) consuming the largest absolute resource amount, confirming their status as the PHC delivery hub. Table 9 Total EPHS Implementation Cost by Facility Type (US $ Million) - Selective Years | Source: Essential Package of Health Services (EPHS) 2020 One Health Tool (OHT) Costing Scenario (2020–2030) | Location: Somalia. Facility Type 2020 Cost (US $ Million) 2025 Cost (US $ Million) 2030 Cost (US $ Million) Community 3.8 13.5 28.6 Primary Health Unit (PHU) 8.4 18.9 57.3 Health Centre (HC) 39.1 89.9 259.0 District Hospital (DH) 27.9 59.0 144.9 Regional Hospital/Office 23.5 47.0 107.2 The efficiency gains derived from the task-sharing model are confirmed by the decline in the average Cost per Patient Visit (CPPV) across most facility types by 2030, signifying successful diversion of routine care to lower-cost settings. Table 10 EPHS Implementation Cost Per Patient Visit by Facility Type (US $ ) | Source: Essential Package of Health Services (EPHS) 2020 One Health Tool (OHT) Costing Scenario (2020–2030) | Location: Somalia. Facility Type 2020 Cost Per Patient Visit (US $ ) 2030 Cost Per Patient Visit (US $ ) Average Cost Per Patient Visit (2020–2030) (US $ ) Community 0.45 0.32 0.40 Primary Health Unit (PHU) 0.42 0.44 0.37 Health Centre (HC) 3.41 2.51 2.63 District Hospital (DH) 4.25 2.42 2.81 Regional Hospital (RH) 14.39 9.37 10.78 3.3.2 NCD and Nutrition Cost Driver Analysis By 2030, the financial dominance of chronic NCD medication is clearly established, with Asthma and Diabetes management consuming 21% of the total drug budget. Table 11 Top 5 Drug and Supply Cost Drivers at Baseline (2020) | Source: Essential Package of Health Services (EPHS) 2020 One Health Tool (OHT) Costing Scenario (2020–2030) | Location: Somalia Intervention Cost (US $ ) Cost % of Total Drugs/Supplies Supplementary feeding for pregnant women with MAM 3 214 454 9% Management of asthma 2 928 811 8% Management of diabetes 2 592 647 7% Supplementary feeding for lactating women with MAM 2 539 221 7% Maternal nutrition assessment, counselling, and MMN 1 420 753 4% Table 12 Top 5 Drug and Supply Cost Drivers at the End Line (2030) | Source: Essential Package of Health Services (EPHS) 2020 One Health Tool (OHT) Costing Scenario (2020–2030) | Location: Somalia. Intervention Cost (US $ ) Cost % of Total Drugs/Supplies Management of asthma 31 437 983 11% Management of diabetes 27 859 289 10% Management of moderate acute malnutrition (children) 12 829 574 5% Abdominal pain, gastritis, and GI bleeding 10 613 015 4% Management of injuries 9 895 010 4% 3.4 Projected Impact on Mortality and Morbidity The scale-up of EPHS 2020 interventions is projected to save an estimated 3,444 maternal lives and 56,265 child lives (0–59 months) in the year 2030 alone, confirming the massive potential return on the US $ 3.1 billion investment. Table 13 Projected Reduction in Child and Maternal Mortality Rates (2020 vs. 2030) | Source: Essential Package of Health Services (EPHS) 2020 One Health Tool (OHT) Impact Projections | Location: Somalia. Indicator (per 1,000 or 100,000 LBs) Baseline (2020) Projected (2030) Expected Reduction (%) Maternal Mortality Ratio (MMR) (per 100,000 LBs) 692 331.6 ~ 52% Neonatal Mortality Rate (per 1,000 LBs) 38 20 ~ 47% Under-Five Mortality Rate (U5MR) (per 1,000 LBs) 122 63 ~ 48% Table 14 Projected Reduction in Global Stunting and Wasting Rates (2020 vs. 2030) | Source: Essential Package of Health Services (EPHS) 2020 One Health Tool (OHT) Impact Projections | Location: Somalia. Indicator Baseline (2020) Projected (2030) Expected Reduction (Percentage Points) Global Stunting Rate (Children 0–59 months) 41.0% 36.6% 4.4% Global Wasting Rate (Children 0–59 months) 13.5% 6.3% 7.2% 4. Discussion 4.1 Interpretation of Findings: The Structural Mandate for Resilience The OHT economic analysis confirms that the EPHS 2020 is not a mere service expansion but a fundamental system transformation. The projected surge of costs toward 60% on medicines and supplies by 2030 is the financial definition of resilience, indicating that the system's long-term success hinges entirely on continuous pharmaceutical supply stability. This mandate for continuity validates the EPHS-ISP’s operational pillars: Task-Sharing and Workforce Resilience : The system must rely on utilization-driven task-sharing, utilizing non-specialist health workers (NPHWs) trained in WHO-PEN/MhGAP to manage the majority of chronic cases. The Female Health Workers ( Marwo Caafimaad ) are the crucial anchor, providing continuous community-based adherence support and screening, which is essential for preserving treatment regimens during shocks. Digital Health and Standardization : Digital platforms are mandatory, not only for telemedicine but primarily as a regulatory tool to enforce standardized clinical protocols (WHO-PEN/MhGAP) and provide resilient supportive supervision and dynamic supply chain monitoring across fragmented FMS boundaries. 4.2 Governance Transformation and Financial Accountability Imperatives The EPHS-ISP's shift to a strategic purchasing model with a purchaser-provider split is the core governance strategy for resilience, enabling the MoH to enforce standards, eliminate duplication ( Geographic Harmonization ), and ensure accountability across the federal structure. However, the sustainability of this entire model is immediately threatened by the 46% Out-of-Pocket Payment (OOP) burden . Policy must target a measurable increase in the domestic government budget (e.g., aiming for 12% by 2030) and urgently scale subsidized health insurance schemes to protect chronic patients from catastrophic health expenditure and ensure adherence to medication. 4.3 Policy Recommendations and Phased Roadmap A structured, phased approach is required to institutionalize integrated PHC resilience: Phase I: Stabilization and Core Governance (Years 1–2) : Secure non-fee based, sustainable public funding for regulatory bodies (NHPC); formalize and fund FHWs; launch MhGAP/WHO-PEN training hubs; and implement Geographic Harmonization. Phase II: Expansion, Digitization, and System Strengthening (Years 3–4) : Scale mHealth infrastructure for supervision and supply chain monitoring; establish NHA and RMET systems; roll out the strategic purchasing model pilot using BSC and PQAT metrics; and ensure forecasted supply of essential NCD/MH medications. Phase III: Transformation and Sustainability (Years 5–7) : Enforce a significant increase in domestic government health expenditure (targeting 12%); scale pilot community-based health insurance models; and institutionalize joint federal-state accountability frameworks to achieve the 80% service coverage goal. 5. Conclusion Somalia's health system transformation requires a fundamental shift to integrated chronic care resilience, validated by economic modeling which projects that 60% of all future costs will be dedicated to sustaining continuous chronic medication and supply . This finding defines the primary challenge and policy priority: establishing stability in supply chains and financial access. Achieving the projected US $ 3.1 billion investment impact, including saving thousands of maternal and child lives annually, necessitates immediate political commitment, a radical reduction in the 46% OOP burden, and the rigorous enforcement of task-sharing and strategic purchasing mechanisms. Integrating NCD and MH care is the central imperative for establishing a stable, equitable, and sustainable health system in a chronically fragile state. Declarations 7.2 Competing Interests The authors declare that they have no competing financial or non-financial interests in the subject matter or materials discussed in this manuscript. 7.4 Ethical Considerations This study constitutes a secondary analysis and policy review based on publicly available strategic documents and economic models. As it did not involve the collection of new primary human subject data, formal ethical approval was not required. The study maintains adherence to the principles of transparency and academic rigor in the representation of all sourced national data. 7.1 Funding 7.3 Data Availability Statement The datasets supporting the conclusions of this article are derived from publicly available national strategic documents and global health estimates cited throughout the manuscript, including the EPHS 2020 Costing Scenario (One Health Tool), Global Burden of Disease estimates 2019, and Federal Ministry of Health policy documents. References Federal Republic of Somalia Ministry of Health (2024) Implementation of Somalia’s National Transformation Plan for Health: a multi-stakeholder roadmap. BMC Health Serv Res 24(1):978 World Health Organization (2024) Somalia: overcoming fragility to build a strong primary health care system. WHO Feature Stories Dirir N, Dirir M (2023) Bridging Non-Communicable Diseases and Mental Health in Primary Health Care: Lessons from Somalia. 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WHO EMRO World Health Organization (2024) Noncommunicable diseases and digital health. WHO EMRO Viatris (2024) Importance of global resilient supply chain access World Health Organization (2021) Policy Brief: Mental Health. WHO EMRO World Health Organization (2025) New framework to bolster health in fragile settings offers timely guidance for countries. WHO News Gerthi Persson (2014) Physical activity as a treatment in primary health care World Health Organization (2022) Metrics and indicators used to assess health system resilience. Health Policy 126(12):1195–1205 Viatris (2024) Importance of global resilient supply chain access World Health Organization (2021) Country Cooperation Strategy for WHO and Somalia 2021–2025 Additional, Sections Additional Declarations The authors declare no competing interests. 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Ministry of Health and Human Services","correspondingAuthor":true,"prefix":"","firstName":"Abdirezak","middleName":"","lastName":"Abdi","suffix":""}],"badges":[],"createdAt":"2025-10-19 15:47:27","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":true,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":true},"doi":"10.21203/rs.3.rs-7899632/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7899632/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":94099761,"identity":"8c5f6280-52d7-4793-b721-def6e8e4004f","added_by":"auto","created_at":"2025-10-22 10:55:25","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":40088,"visible":true,"origin":"","legend":"","description":"","filename":"RevisedmuniscriptofBuildingResilientPrimaryHealthCareinSomalia....docx","url":"https://assets-eu.researchsquare.com/files/rs-7899632/v1/14c51d88300e079887b4b093.docx"},{"id":94099762,"identity":"0a814c3b-b98a-447a-8b29-314341eb71fc","added_by":"auto","created_at":"2025-10-22 10:55:25","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":342,"visible":true,"origin":"","legend":"","description":"","filename":"rs7899632.json","url":"https://assets-eu.researchsquare.com/files/rs-7899632/v1/d3cbd8e00acbbb8bddc1060a.json"},{"id":94099763,"identity":"babfea73-0949-4e5b-a738-95013253f9dd","added_by":"auto","created_at":"2025-10-22 10:55:25","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":85553,"visible":true,"origin":"","legend":"","description":"","filename":"rs78996320enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7899632/v1/7ad4cded9cce3134dd717a39.xml"},{"id":94099764,"identity":"6e7866a1-2175-48b9-b89f-3aeb6e7c3c6b","added_by":"auto","created_at":"2025-10-22 10:55:25","extension":"xml","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":82586,"visible":true,"origin":"","legend":"","description":"","filename":"rs78996320structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7899632/v1/fa422263486625c86c705477.xml"},{"id":94099913,"identity":"cf29a110-8837-4cd5-b4f2-ce361b0a0575","added_by":"auto","created_at":"2025-10-22 11:03:25","extension":"html","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":95409,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7899632/v1/0f8024a796188be3f77b2df2.html"},{"id":94100633,"identity":"a1333948-bd23-4c0d-bc83-b7f3d1b1d0f6","added_by":"auto","created_at":"2025-10-22 11:11:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2470482,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7899632/v1/f1362d73-80dd-43e0-b83f-a1326dbd5126.pdf"},{"id":94099766,"identity":"2bb9cd15-cfb5-495b-a5be-3e091f4310b0","added_by":"auto","created_at":"2025-10-22 10:55:25","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":5113,"visible":true,"origin":"","legend":"","description":"","filename":"AdditionalSections.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7899632/v1/2ae0f948372b8f98b43f2db9.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eBuilding Resilient Primary Health Care in Somalia: Integrating Non-Communicable Disease and Mental Health Interventions for Universal Health Coverage amidst Fragility\u003cbr\u003e\n\u003c/p\u003e","fulltext":[{"header":"1. Introduction","content":"\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e\u003ch2\u003e1.1 Background: The Acute Crisis of Chronic Care in FCAS\u003c/h2\u003e\u003cp\u003eGlobal public health efforts have historically defaulted to an acute, crisis-driven response in Fragile and Conflict-Affected States (FCAS), prioritizing immediate trauma care and infectious disease control. This approach is now structurally insufficient. Prolonged instability, coupled with global demographic and epidemiological shifts, means that FCAS populations are increasingly susceptible to a chronic disease burden that existing systems are incapable of managing.\u003c/p\u003e\u003cp\u003eIn Somalia, three decades of civil war, weak governance, and continuous humanitarian shocks have resulted in a system characterized by profound fragility. This environment severely restricts access to continuous, life-long chronic care, including essential medications and mental health support, leading to significantly higher mortality rates among people living with NCDs (PLWNCDs). The inability to maintain the \u003cb\u003econtinuity of essential services\u003c/b\u003e\u0026mdash;a core requirement for NCD and MH management\u0026mdash;during periods of shock highlights a critical systemic vulnerability: the lack of health system resilience. The paradigm shift mandated by the EPHS 2020, transitioning from fragmented aid to an integrated PHC platform, is a direct response to this failure, aligning Somalia\u0026rsquo;s strategy with the global call to integrate health security and long-term PHC resilience in FCV settings.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e1.2 Somalia\u0026rsquo;s Structural Deficits and Dual Burden\u003c/h2\u003e\u003cp\u003eThe structural crisis is evidenced by Somalia's UHC index of only 25% and a health workforce density of only 0.11 clinicians per 1,000 population, contrasting sharply with the WHO target of 2.28 per 1,000. The average life expectancy is approximately 56 years.\u003c/p\u003e\u003cp\u003eWhile the historical burden of communicable diseases (CDs), maternal, neonatal, and nutritional disorders still account for 68.8% of total Disability-Adjusted Life Years (DALYs), the nation is undergoing a rapid epidemiological transition toward chronic illness. Non-Communicable diseases (NCDs) are responsible for approximately \u003cb\u003e42% of total mortality\u003c/b\u003e in 2019. This burden is inextricably linked to a massive mental health crisis, with depression and anxiety estimated to affect \u003cb\u003eone in three individuals\u003c/b\u003e\u0026mdash;a prevalence significantly exceeding global averages. Mental disorders rank thirteenth among the top health problems causing long-term disability, as measured by Years Lived with Disability (YLDs).\u003c/p\u003e\u003cp\u003eThe immediate necessity for comprehensive service expansion and integration is detailed in the baseline health indicators below.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSomalia's Key Health Indicators and Service Coverage (2006\u0026ndash;2020) | Source: Federal Ministry of Health, Global Health Estimates, Somalia UHC Index (Approx. 2020 Baseline) | Location: Somalia.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIndicator\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2006\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2016\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2019/2020 (Baseline)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMaternal Mortality Ratio (per 100,000 LBs)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1040\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e865\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e692\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnder-five Mortality Rate (per 1,000 LBs)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e170.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e128.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e122\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBirths Attended by Skilled Personnel (Coverage)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN/A\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eN/A\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e32%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChildren Fully Immunised (Coverage)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN/A\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eN/A\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUHC Index\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN/A\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eN/A\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e25%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e1.3 Financial Instability: The Impasse of Out-of-Pocket Payments\u003c/h2\u003e\u003cp\u003eLow public investment (annual per capita health expenditure of US\u003cspan\u003e$\u003c/span\u003e13) translates directly into a crippling financial burden on citizens. Out-of-Pocket Payments (OOP) constitute a staggering \u003cb\u003e46% of total health expenditure\u003c/b\u003e. This level of catastrophic spending severely restricts access to long-term chronic care, compromising the financial protection pillar of UHC. Financial stability is further undermined by high reliance on fragmented external donor contributions (38% share) and insufficient domestic government expenditure (15% share), leading to a volatile and unsustainable financing environment.\u003c/p\u003e\u003cp\u003eThe financial structure that necessitates transformation through strategic purchasing is summarized below.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eHealth Financing Structure and Barriers (Approx. 2020 Baseline) | Source: Federal Ministry of Health, National Health Accounts (Approx. 2020 Baseline) | Location: Somalia\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMetric\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eValue\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eImplication for UHC\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnnual Per Capita Health Expenditure (Total)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUS\u003cspan\u003e$\u003c/span\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCritically low compared to regional averages (SSA average \u003cspan\u003e$\u003c/span\u003e204).\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOut-of-Pocket Payments (OOP) Share\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e46%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMajor barrier to access; compromises UHC financial protection pillar.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDonor Contribution Share (Off-treasury)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e38%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHigh reliance on fragmented, unpredictable external funding.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGovernment Expenditure Share\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eInsufficient domestic commitment for sustainable health system.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e1.4 Objectives\u003c/h2\u003e\u003cp\u003eThis study performs a rigorous analysis and quantification of Somalia\u0026rsquo;s strategic shift to integrate chronic care into its PHC system via the EPHS 2020. The specific objectives are:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eTo evaluate the systemic fragilities and epidemiological drivers (YLD vs. YLL analysis) mandating the integration of NCD and MH services into the core PHC platform.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eTo analyze and elaborate the operational frameworks of the EPHS 2020, focusing on the mandated adoption of WHO-PEN/MhGAP protocols, utilization-driven task-sharing, and digital health as foundations for service resilience.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eTo present and interpret the economic projections from the One Health Tool (OHT) Costing Scenario (2020\u0026ndash;2030), specifically quantifying the total investment, the structural cost shift toward chronic supplies, and the projected efficiency gains required to achieve the UHC target.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.1 Study Design: Health Systems Analysis and Prospective Economic Modeling Review\u003c/h2\u003e\u003cp\u003eThe research employs a robust \u003cb\u003eHealth Systems Analysis and Prospective Economic Modeling Review\u003c/b\u003e design. This design was chosen as the most appropriate methodology for national policy planning in a complex, data-scarce, and fragile setting like Somalia. Unlike a retrospective systematic review or an empirical study, this design synthesizes qualitative findings on governance and operational challenges with quantitative, forward-looking economic forecasts to create an evidence-based roadmap for systemic transformation.\u003c/p\u003e\u003cp\u003eThe design\u0026rsquo;s primary function is to interpret and validate the Federal Government of Somalia\u0026rsquo;s policy intent\u0026mdash;the EPHS 2020\u0026mdash;against the actual projected resource requirements and health impact.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Setting, Scope, and Data Sourcing Rationale\u003c/h2\u003e\u003cdiv id=\"Sec8\" class=\"Section3\"\u003e\u003ch2\u003e2.2.1 Setting and Scope\u003c/h2\u003e\u003cp\u003eThe study setting is the Federal Republic of Somalia, characterized by a decentralized, federal governance structure that frequently contributes to service fragmentation and coordination challenges. The study scope is national, encompassing all Primary Health Care (PHC) interventions and community-level services defined by the EPHS 2020.\u003c/p\u003e\u003cp\u003eThe economic modeling component is framed over a ten-year projection period, from baseline (2020) to the UHC target year (2030). The goal of the modeling is to quantify the costs associated with scaling service coverage from the baseline of \u003cb\u003e25%\u003c/b\u003e to the ambitious national UHC target of \u003cb\u003e80%\u003c/b\u003e coverage for the Core EPHS package by 2030.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section3\"\u003e\u003ch2\u003e2.2.2 Data Sources and Rationale\u003c/h2\u003e\u003cp\u003eData were synthesized from authoritative sources, explicitly chosen to address the epidemiological, financial, and planning requirements of a resilient health system:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eEpidemiological Data\u003c/b\u003e: Baseline disease burden data, including YLL, YLD, and DALYs, were extracted from the \u003cb\u003eGlobal Burden of Disease (GBD) estimates for Somalia (2019)\u003c/b\u003e. This data source provided the intellectual justification for the NCD/MH integration, demonstrating that chronic disability (YLD) is dominated by NCDs and Mental Health disorders, necessitating a shift away from a sole focus on acute mortality (YLL) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eHealth Financing Metrics\u003c/b\u003e: Baseline financial data (per capita expenditure, OOP share, government allocation) were sourced from \u003cb\u003eNational Health Accounts (NHA) reports\u003c/b\u003e and \u003cb\u003eMinistry of Finance budget execution reports\u003c/b\u003e (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). These data quantify the severity of the financial protection gap and establish the baseline fiscal space that must be expanded.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003ePolicy and Operational Documents\u003c/b\u003e: The \u003cb\u003eEPHS 2020\u003c/b\u003e and its \u003cb\u003eImplementation Strategic Plan (EPHS-ISP)\u003c/b\u003e served as the foundational operational blueprint. These documents provided the qualitative inputs regarding the mandated clinical protocols, task-sharing models, and governance strategies (Table\u0026nbsp;4, Table\u0026nbsp;5).\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003e2.3 Economic Modeling Methodology: The One Health Tool (OHT) Application\u003c/h2\u003e\u003cp\u003eThe core quantitative analysis relies on the \u003cb\u003eOne Health Tool (OHT)\u003c/b\u003e, an internationally standardized software platform used by WHO and partners for national health sector strategic planning and resource forecasting. The OHT is a deterministic model that calculates resource requirements based on target populations, desired service coverage levels, and established unit costs.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section3\"\u003e\u003ch2\u003e2.3.1 Key Modeling Parameters and Inputs\u003c/h2\u003e\u003cp\u003eThe OHT was applied to the EPHS 2020 Costing Scenario using meticulously defined parameters:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eTarget Coverage\u003c/b\u003e: The model explicitly scaled the EPHS interventions to reach \u003cb\u003e80% coverage by 2030\u003c/b\u003e, reflecting the official national UHC commitment.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eIntervention Integration\u003c/b\u003e: The model inputs systematically incorporated the full resource costs of the newly mandated chronic care interventions: the \u003cb\u003eWHO Package of Essential Non-Communicable Disease Interventions (WHO-PEN)\u003c/b\u003e and the \u003cb\u003eMental Health Gap Action Programme (MhGAP)\u003c/b\u003e. This integration included the procurement of standardized essential medicines (e.g., insulin, anti-hypertensive, and psychotropic), specialized NCD/MH diagnostics, and the cost of non-physician health worker (NPHW) training modules (MhGAP training).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eWorkforce Costing\u003c/b\u003e: The model utilized the \u003cb\u003eutilization-driven staffing\u003c/b\u003e model mandated by the EPHS 2020, which links staffing levels to projected patient volume in specific geographic areas. This methodology accurately costed the expanded deployment and supervision of lower-cost resources, such as \u003cb\u003eFemale Health Workers (FHWs)\u003c/b\u003e, ensuring a rationalized cost for the task-sharing approach.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section3\"\u003e\u003ch2\u003e2.3.2 Cost Components and Analysis Output\u003c/h2\u003e\u003cp\u003eTotal costs were rigorously broken down across five categories to identify the source and trajectory of expenditure (Tables\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e7\u003c/span\u003e, \u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e8\u003c/span\u003e):\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eHuman Resources (Salaries)\u003c/b\u003e: Initial investment in training and salaries for the expanded workforce.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eInfrastructure\u003c/b\u003e: Costs for facility rehabilitation and new builds (e.g., PHUs, Health Centers).\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eMedicines and Supplies\u003c/b\u003e: This component captured the entire pharmaceutical load, critically including the continuous supply required for chronic care management (NCDs, MH, and Nutrition).\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eLogistics\u003c/b\u003e: Transportation, storage, and distribution costs. In Somalia, this component is disproportionately important due to high insecurity, distance barriers, and the need for resilient, frequent distribution to remote areas (reflected in the projected 10% proportional increase by 2030, Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eProgramme Costs\u003c/b\u003e: Management, supportive supervision, and quality assurance overhead.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eThe primary output analyzed was the \u003cb\u003estructural shift in cost composition\u003c/b\u003e, specifically the proportional increase of the Medicines and Supplies component, which served as the quantitative evidence of the system's shift toward a chronic care footing.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003e2.4 Integrated Analytical Frameworks\u003c/h2\u003e\u003cp\u003eThe EPHS 2020 operates as the primary integrated framework, built on the principle of \u003cb\u003eProgressive Realization\u003c/b\u003e, dividing services into a mandatory \u003cb\u003eCore Package\u003c/b\u003e and a long-term \u003cb\u003eExtended Package\u003c/b\u003e.\u003c/p\u003e\u003cdiv id=\"Sec14\" class=\"Section3\"\u003e\u003ch2\u003e2.4.1 Clinical Methodology: WHO-PEN and MhGAP Integration\u003c/h2\u003e\u003cp\u003eThe mandated integration of chronic care utilizes two internationally validated clinical methodologies:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eWHO-PEN\u003c/b\u003e: The \u003cb\u003ePackage of Essential Non-Communicable Disease Interventions\u003c/b\u003e provides a standardized, simplified clinical algorithm for NCD diagnosis and management at the PHC level. The EPHS emphasizes the \u003cb\u003etotal cardiovascular risk approach\u003c/b\u003e\u0026mdash;a cost-effective strategy that targets limited resources (e.g., essential anti-hypertensives) to individuals with the highest calculated absolute risk of a cardiovascular event, maximizing population health impact in a resource-constrained environment.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eMhGAP\u003c/b\u003e: The \u003cb\u003eMental Health Gap Action Programme\u003c/b\u003e provides a framework for task-sharing mental health interventions, using non-specialist health workers (NPHWs and FHWs) to manage priority conditions like depression and anxiety at the community and PHC level. This approach is essential for achieving the required high coverage in Somalia, where specialty services are virtually non-existent.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section3\"\u003e\u003ch2\u003e2.4.2 Governance Methodology: Strategic Purchasing and Accountability\u003c/h2\u003e\u003cp\u003eTo counteract the fragmentation inherent in the federal structure, the methodology analyzed the shift to a strategic governance model (Table\u0026nbsp;5):\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003ePurchaser-Provider Split (PPS)\u003c/b\u003e: This model separates the stewardship function (policy-setting, financial risk management, quality control by the MoH) from the delivery function (NGOs and private sector providers). This separation enhances accountability, enabling the MoH to enforce standardized EPHS compliance through contracting.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003ePerformance Monitoring\u003c/b\u003e: The use of \u003cb\u003eBalanced Score Cards (BSC)\u003c/b\u003e and the \u003cb\u003ePerformance/Quality Assessment Tool (PQAT)\u003c/b\u003e was analyzed as the mechanism for ensuring that contracted providers adhere to EPHS quality standards (including NCD/MH service delivery) and for tracking UHC tracer indicators across FMS, promoting federal-state accountability.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003e2.5 Ethical Considerations\u003c/h2\u003e\u003cp\u003eAs this analysis is a review and synthesis of secondary policy data (EPHS 2020) and economic projections (OHT), it was exempt from primary human subjects review. The methodological rigor, however, adhered to the highest standards of transparency and accuracy in representing national strategic data and projections.\u003c/p\u003e\u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Burden of Disease Analysis: Justification for Chronic Care Integration\u003c/h2\u003e\u003cp\u003eThe GBD 2019 analysis confirms that the primary challenge is tackling chronic disability (YLD) to improve quality of life and productivity, complementing ongoing efforts to reduce acute mortality (YLL).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBurden of Disease Analysis: Top 5 Causes of Years of Life Lost (YLL) and Years Lived with Disability (YLD) (2019) | Source: Global Burden of Diseases estimates (2019) | Location: Somalia\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTop 5 Causes of Years of Life Lost (YLL)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePrimary Disease Group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTop 5 Causes of Years Lived with Disability (YLD)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePrimary Disease Group\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNeonatal disorders\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMaternal/Neonatal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDepressive disorders\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMental Health/NCD\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLower respiratory infections\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCommunicable Disease\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLow back pain\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNCD\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDiarrheal diseases\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCommunicable Disease\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eGynecological diseases\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNCD\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTuberculosis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCommunicable Disease\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHeadache disorders\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNCD\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMeasles\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCommunicable Disease\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAge related and other Anxiety disorders\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMental Health/NCD\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cb\u003eSource: Global Burden of Diseases estimates (2019)\u003c/b\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe YLD data confirms that \u003cb\u003eDepressive disorders, Low back pain, Headache disorders, and Anxiety disorders\u003c/b\u003e dominate the chronic disability metrics, providing the epidemiological mandate for the systematic integration of WHO-PEN and MhGAP protocols within the EPHS 2020 framework.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003e3.2 Economic Findings: Total Costs and Structural Cost Transformation\u003c/h2\u003e\u003cdiv id=\"Sec20\" class=\"Section3\"\u003e\u003ch2\u003e3.2.1 Total Projected Costs and Per Capita Expenditure\u003c/h2\u003e\u003cp\u003eThe OHT model projects a required total investment of \u003cb\u003eUS\u003cspan\u003e$\u003c/span\u003e3.1\u0026nbsp;billion\u003c/b\u003e over 2020\u0026ndash;2030 to achieve 80% coverage, requiring annual per capita spending to increase from \u003cspan\u003e$\u003c/span\u003e7.4 in 2020 to \u003cspan\u003e$\u003c/span\u003e33.3 by 2030.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eEPHS 2020 Per Capita Costs and Total Projected Cost (US\u003cspan\u003e$\u003c/span\u003e Million) | Source: Essential Package of Health Services (EPHS) 2020 One Health Tool (OHT) Costing Scenario (2020\u0026ndash;2030) | Location: Somalia)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYear\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePer Capita Cost (US\u003cspan\u003e$\u003c/span\u003e)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eGrand Total Cost (US\u003cspan\u003e$\u003c/span\u003e million)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2020\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e104.54\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2025\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e231.56\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2030\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e33.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e625.47\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal (2020\u0026ndash;2030)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN/A\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3106.03\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section3\"\u003e\u003ch2\u003e3.2.2 Composition of Costs: The Definitive Shift to Chronic Care Supplies\u003c/h2\u003e\u003cp\u003eThe most significant finding validating the EPHS 2020 strategy is the structural shift in cost composition: \u003cb\u003eMedicines and Supplies cost is projected to increase from 34% in 2020 to 60% by 2030\u003c/b\u003e. This quantitatively confirms that the long-term cost of the Somali health system will be dominated by the sustained, consumption-based requirements of managing chronic NCD and MH patients.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComposition of EPHS 2020 Implementation Costs (US\u003cspan\u003e$\u003c/span\u003e Million) from 2020 to 2030 | Source: Essential Package of Health Services (EPHS) 2020 One Health Tool (OHT) Costing Scenario (2020\u0026ndash;2030) | Location: Somalia\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCost Component\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2020 (US\u003cspan\u003e$\u003c/span\u003e Million)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2030 (US\u003cspan\u003e$\u003c/span\u003e Million)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTotal (2020\u0026ndash;2030) (US\u003cspan\u003e$\u003c/span\u003e Million)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal Human Resources (Salaries)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e48.22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e118.58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e895.34\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal Infrastructure Cost\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e13.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e128.93\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal Medicines and Supplies Cost\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e36.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e375.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1594.26\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal Logistics Cost\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e9.63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e117.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e474.22\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal Programme Costs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1.46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e13.29\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGrand Total\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e104.54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e625.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3106.03\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 8\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePercentage Distribution of EPHS Cost Components (Visualizing the Shift) | Source: Essential Package of Health Services (EPHS) 2020 One Health Tool (OHT) Costing Scenario (2020\u0026ndash;2030) | Location: Somalia\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCost Component\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2020 (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2030 (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eChange (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eImplication for Chronic Care\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHuman Resources (Salaries)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e46%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-27%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eDecreasing relative importance post-initial investment.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedicines and Supplies\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e34%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e60%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e+\u0026thinsp;26%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eDominant driver by 2030; reflects sustained chronic medication needs.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInfrastructure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-8%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eDecreasing relative importance post-initial rehabilitation.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLogistics\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e+\u0026thinsp;10%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eIncrease proportional to drug/supply distribution scale.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003e3.3 Resource Allocation, Efficiency, and Dominant Cost Drivers\u003c/h2\u003e\u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\u003ch2\u003e3.3.1 Resource Allocation by Facility Type and Efficiency Gains\u003c/h2\u003e\u003cp\u003eThe decentralized nature of the EPHS is reflected in the allocation, with Health Centres (HCs) consuming the largest absolute resource amount, confirming their status as the PHC delivery hub.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 9\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eTotal EPHS Implementation Cost by Facility Type (US\u003cspan\u003e$\u003c/span\u003e Million) - Selective Years | Source: Essential Package of Health Services (EPHS) 2020 One Health Tool (OHT) Costing Scenario (2020\u0026ndash;2030) | Location: Somalia.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFacility Type\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2020 Cost (US\u003cspan\u003e$\u003c/span\u003e Million)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2025 Cost (US\u003cspan\u003e$\u003c/span\u003e Million)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2030 Cost (US\u003cspan\u003e$\u003c/span\u003e Million)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCommunity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e13.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e28.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrimary Health Unit (PHU)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e8.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e18.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e57.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealth Centre (HC)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e39.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e89.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e259.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDistrict Hospital (DH)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e27.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e59.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e144.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRegional Hospital/Office\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e23.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e47.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e107.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe efficiency gains derived from the task-sharing model are confirmed by the decline in the average \u003cb\u003eCost per Patient Visit (CPPV)\u003c/b\u003e across most facility types by 2030, signifying successful diversion of routine care to lower-cost settings.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab8\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 10\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eEPHS Implementation Cost Per Patient Visit by Facility Type (US\u003cspan\u003e$\u003c/span\u003e) | Source: Essential Package of Health Services (EPHS) 2020 One Health Tool (OHT) Costing Scenario (2020\u0026ndash;2030) | Location: Somalia.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFacility Type\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2020 Cost Per Patient Visit (US\u003cspan\u003e$\u003c/span\u003e)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2030 Cost Per Patient Visit (US\u003cspan\u003e$\u003c/span\u003e)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAverage Cost Per Patient Visit (2020\u0026ndash;2030) (US\u003cspan\u003e$\u003c/span\u003e)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCommunity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.40\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrimary Health Unit (PHU)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.37\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealth Centre (HC)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2.51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.63\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDistrict Hospital (DH)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2.42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.81\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRegional Hospital (RH)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e14.39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9.37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e10.78\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec24\" class=\"Section3\"\u003e\u003ch2\u003e3.3.2 NCD and Nutrition Cost Driver Analysis\u003c/h2\u003e\u003cp\u003eBy 2030, the financial dominance of chronic NCD medication is clearly established, with Asthma and Diabetes management consuming 21% of the total drug budget.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab9\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 11\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eTop 5 Drug and Supply Cost Drivers at Baseline (2020) | Source: Essential Package of Health Services (EPHS) 2020 One Health Tool (OHT) Costing Scenario (2020\u0026ndash;2030) | Location: Somalia\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntervention\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCost (US\u003cspan\u003e$\u003c/span\u003e)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCost % of Total Drugs/Supplies\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSupplementary feeding for pregnant women with MAM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 214 454\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eManagement of asthma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 928 811\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eManagement of diabetes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 592 647\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSupplementary feeding for lactating women with MAM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 539 221\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMaternal nutrition assessment, counselling, and MMN\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 420 753\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab10\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 12\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eTop 5 Drug and Supply Cost Drivers at the End Line (2030) | Source: Essential Package of Health Services (EPHS) 2020 One Health Tool (OHT) Costing Scenario (2020\u0026ndash;2030) | Location: Somalia.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntervention\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCost (US\u003cspan\u003e$\u003c/span\u003e)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCost % of Total Drugs/Supplies\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eManagement of asthma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e31 437 983\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eManagement of diabetes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e27 859 289\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eManagement of moderate acute malnutrition (children)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12 829 574\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAbdominal pain, gastritis, and GI bleeding\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10 613 015\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eManagement of injuries\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9 895 010\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec25\" class=\"Section2\"\u003e\u003ch2\u003e3.4 Projected Impact on Mortality and Morbidity\u003c/h2\u003e\u003cp\u003eThe scale-up of EPHS 2020 interventions is projected to save an estimated \u003cb\u003e3,444 maternal lives\u003c/b\u003e and \u003cb\u003e56,265 child lives\u003c/b\u003e (0\u0026ndash;59 months) in the year 2030 alone, confirming the massive potential return on the US\u003cspan\u003e$\u003c/span\u003e3.1\u0026nbsp;billion investment.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab11\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 13\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eProjected Reduction in Child and Maternal Mortality Rates (2020 vs. 2030) | Source: Essential Package of Health Services (EPHS) 2020 One Health Tool (OHT) Impact Projections | Location: Somalia.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIndicator (per 1,000 or 100,000 LBs)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBaseline (2020)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eProjected (2030)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eExpected Reduction (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMaternal Mortality Ratio (MMR) (per 100,000 LBs)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e692\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e331.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e~\u0026thinsp;52%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNeonatal Mortality Rate (per 1,000 LBs)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e~\u0026thinsp;47%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnder-Five Mortality Rate (U5MR) (per 1,000 LBs)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e122\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e~\u0026thinsp;48%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab12\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 14\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eProjected Reduction in Global Stunting and Wasting Rates (2020 vs. 2030) | Source: Essential Package of Health Services (EPHS) 2020 One Health Tool (OHT) Impact Projections | Location: Somalia.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIndicator\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBaseline (2020)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eProjected (2030)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eExpected Reduction (Percentage Points)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGlobal Stunting Rate (Children 0\u0026ndash;59 months)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e41.0%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e36.6%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4.4%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGlobal Wasting Rate (Children 0\u0026ndash;59 months)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e13.5%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6.3%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e7.2%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cdiv id=\"Sec27\" class=\"Section2\"\u003e\u003ch2\u003e4.1 Interpretation of Findings: The Structural Mandate for Resilience\u003c/h2\u003e\u003cp\u003eThe OHT economic analysis confirms that the EPHS 2020 is not a mere service expansion but a fundamental system transformation. The projected surge of costs toward \u003cb\u003e60% on medicines and supplies by 2030\u003c/b\u003e is the financial definition of resilience, indicating that the system's long-term success hinges entirely on continuous pharmaceutical supply stability.\u003c/p\u003e\u003cp\u003eThis mandate for continuity validates the EPHS-ISP\u0026rsquo;s operational pillars:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eTask-Sharing and Workforce Resilience\u003c/b\u003e: The system must rely on utilization-driven task-sharing, utilizing non-specialist health workers (NPHWs) trained in \u003cb\u003eWHO-PEN/MhGAP\u003c/b\u003e to manage the majority of chronic cases. The Female Health Workers (\u003cem\u003eMarwo Caafimaad\u003c/em\u003e) are the crucial anchor, providing continuous community-based adherence support and screening, which is essential for preserving treatment regimens during shocks.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eDigital Health and Standardization\u003c/b\u003e: Digital platforms are mandatory, not only for telemedicine but primarily as a \u003cb\u003eregulatory tool\u003c/b\u003e to enforce standardized clinical protocols (WHO-PEN/MhGAP) and provide resilient supportive supervision and dynamic supply chain monitoring across fragmented FMS boundaries.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec28\" class=\"Section2\"\u003e\u003ch2\u003e4.2 Governance Transformation and Financial Accountability Imperatives\u003c/h2\u003e\u003cp\u003eThe EPHS-ISP's shift to a \u003cb\u003estrategic purchasing model\u003c/b\u003e with a \u003cb\u003epurchaser-provider split\u003c/b\u003e is the core governance strategy for resilience, enabling the MoH to enforce standards, eliminate duplication (\u003cb\u003eGeographic Harmonization\u003c/b\u003e), and ensure accountability across the federal structure. However, the sustainability of this entire model is immediately threatened by the \u003cb\u003e46% Out-of-Pocket Payment (OOP) burden\u003c/b\u003e. Policy must target a measurable increase in the domestic government budget (e.g., aiming for 12% by 2030) and urgently scale subsidized health insurance schemes to protect chronic patients from catastrophic health expenditure and ensure adherence to medication.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec29\" class=\"Section2\"\u003e\u003ch2\u003e4.3 Policy Recommendations and Phased Roadmap\u003c/h2\u003e\u003cp\u003eA structured, phased approach is required to institutionalize integrated PHC resilience:\u003c/p\u003e\u003cp\u003e\u003cb\u003ePhase I: Stabilization and Core Governance (Years 1\u0026ndash;2)\u003c/b\u003e: Secure non-fee based, sustainable public funding for regulatory bodies (NHPC); formalize and fund FHWs; launch MhGAP/WHO-PEN training hubs; and implement Geographic Harmonization.\u003c/p\u003e\u003cp\u003e\u003cb\u003ePhase II: Expansion, Digitization, and System Strengthening (Years 3\u0026ndash;4)\u003c/b\u003e: Scale mHealth infrastructure for supervision and supply chain monitoring; establish \u003cb\u003eNHA\u003c/b\u003e and \u003cb\u003eRMET\u003c/b\u003e systems; roll out the \u003cb\u003estrategic purchasing model\u003c/b\u003e pilot using \u003cb\u003eBSC\u003c/b\u003e and \u003cb\u003ePQAT\u003c/b\u003e metrics; and ensure forecasted supply of essential NCD/MH medications.\u003c/p\u003e\u003cp\u003e\u003cb\u003ePhase III: Transformation and Sustainability (Years 5\u0026ndash;7)\u003c/b\u003e: Enforce a significant increase in domestic government health expenditure (targeting 12%); scale pilot community-based health insurance models; and institutionalize joint federal-state accountability frameworks to achieve the \u003cb\u003e80% service coverage\u003c/b\u003e goal.\u003c/p\u003e\u003c/div\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eSomalia's health system transformation requires a fundamental shift to integrated chronic care resilience, validated by economic modeling which projects that \u003cb\u003e60% of all future costs will be dedicated to sustaining continuous chronic medication and supply\u003c/b\u003e. This finding defines the primary challenge and policy priority: establishing stability in supply chains and financial access. Achieving the projected US\u003cspan\u003e$\u003c/span\u003e3.1\u0026nbsp;billion investment impact, including saving thousands of maternal and child lives annually, necessitates immediate political commitment, a radical reduction in the 46% OOP burden, and the rigorous enforcement of task-sharing and strategic purchasing mechanisms. Integrating NCD and MH care is the central imperative for establishing a stable, equitable, and sustainable health system in a chronically fragile state.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003e7.2 Competing Interests\u003c/h2\u003e\u003cp\u003eThe authors declare that they have no competing financial or non-financial interests in the subject matter or materials discussed in this manuscript.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003e7.4 Ethical Considerations\u003c/h2\u003e\u003cp\u003eThis study constitutes a secondary analysis and policy review based on publicly available strategic documents and economic models. As it did not involve the collection of new primary human subject data, formal ethical approval was not required. The study maintains adherence to the principles of transparency and academic rigor in the representation of all sourced national data.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003e7.1 Funding\u003c/h2\u003e\u003ch2\u003e7.3 Data Availability Statement\u003c/h2\u003e\u003cp\u003eThe datasets supporting the conclusions of this article are derived from publicly available national strategic documents and global health estimates cited throughout the manuscript, including the EPHS 2020 Costing Scenario (One Health Tool), Global Burden of Disease estimates 2019, and Federal Ministry of Health policy documents.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eFederal Republic of Somalia Ministry of Health (2024) Implementation of Somalia\u0026rsquo;s National Transformation Plan for Health: a multi-stakeholder roadmap. 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June\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization (2022) Community health worker programmes: A call for better funding and integration. Front Public Health 10:1073617\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization (2020) OneHealth tool. Avenir Health, Glastonbury\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMinistry of Health and Human Services (2021) Federal Republic of Somalia. \u003cem\u003eEssential Package of Health Services (EPHS) Somalia, 2020\u003c/em\u003e. June\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWorld Diabetes Foundation WDF24-1949: NCD Kits for Emergencies in the WHO Eastern Mediterranean Region\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGFF Secretariat (2020) Somalia Investment Case: Accelerating Progress on RMNCAH and Nutrition. 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WHO EMRO\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization (2024) Noncommunicable diseases and digital health. WHO EMRO\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eViatris (2024) Importance of global resilient supply chain access\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization (2021) Policy Brief: Mental Health. WHO EMRO\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization (2025) New framework to bolster health in fragile settings offers timely guidance for countries. WHO News\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGerthi Persson (2014) Physical activity as a treatment in primary health care\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization (2022) Metrics and indicators used to assess health system resilience. Health Policy 126(12):1195\u0026ndash;1205\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eViatris (2024) Importance of global resilient supply chain access\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization (2021) Country Cooperation Strategy for WHO and Somalia 2021\u0026ndash;2025\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAdditional, Sections\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Benadir University","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Health system resilience, Universal Health Coverage, Non-Communicable diseases, mental health, primary health care, Essential Package of Health Services, health financing, task-sharing, digital health.","lastPublishedDoi":"10.21203/rs.3.rs-7899632/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7899632/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eSomalia\u0026rsquo;s health system is defined by extreme, chronic fragility, exemplified by a critically low Universal Health Coverage (UHC) index of \u003cb\u003e25%\u003c/b\u003e and a severe health workforce shortage, with only \u003cb\u003e0.11 clinicians per 1,000 population\u003c/b\u003e. This systemic weakness, a legacy of three decades of conflict and humanitarian crisis, intersects with an accelerating dual burden of Non-Communicable Diseases (NCDs) and Mental Health (MH) disorders. NCDs account for approximately \u003cb\u003e42% of total mortality\u003c/b\u003e, while the pervasive impact of violence and displacement means MH disorders affect an estimated \u003cb\u003eone in three individuals\u003c/b\u003e. This manuscript presents a comprehensive health systems analysis and prospective economic projection of Somalia\u0026rsquo;s strategic shift toward an integrated Primary Health Care (PHC) model designed for resilience in fragile, conflict-affected settings (FCAS). Utilizing the rigorous One Health Tool (OHT) for the EPHS 2020 Implementation Strategic Plan (EPHS-ISP), we model the resource needs required to achieve 80% coverage by 2030. The analysis projects a total investment of \u003cb\u003eUS$3.1\u0026nbsp;billion\u003c/b\u003e over the decade. Critically, the economic findings confirm a profound structural transformation: the costs required for continuous chronic care\u0026mdash;specifically essential medicines and supplies\u0026mdash;will surge to constitute \u003cb\u003e60% of total implementation costs by 2030\u003c/b\u003e. This finding mandates immediate operationalization of the strategic purchasing model, aggressive, utilization-driven task-sharing leveraging Female Health Workers (FHWs) trained in WHO-PEN/MhGAP protocols, and robust digital health integration for resilient supply chain management. We conclude that sustainable UHC and long-term health security in Somalia rely on institutionalizing chronic care resilience within the core PHC platform, supported by stable domestic financing and rigorous, performance-based governance.\u003c/p\u003e","manuscriptTitle":"Building Resilient Primary Health Care in Somalia: Integrating Non-Communicable Disease and Mental Health Interventions for Universal Health Coverage amidst Fragility","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-22 10:55:20","doi":"10.21203/rs.3.rs-7899632/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cce562d8-e7bb-4eeb-be71-f63b574c7155","owner":[],"postedDate":"October 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":56546127,"name":"Health Policy"}],"tags":[],"updatedAt":"2025-10-22T10:55:20+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-22 10:55:20","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7899632","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7899632","identity":"rs-7899632","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}