The Silent Epidemic: Strengthening Governance and Health System Resilience against Non-Communicable Diseases in Somalia

The Silent Epidemic: Strengthening Governance and Health System Resilience against Non-Communicable Diseases in Somalia | 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 The Silent Epidemic: Strengthening Governance and Health System Resilience against Non-Communicable Diseases in Somalia Abdirezak Abdi, Abubakar jama This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7923919/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 Background Non-Communicable diseases (NCDs) such as cardiovascular issues, diabetes, various cancers, and chronic respiratory diseases are becoming a significant public health issue in Somalia, a country affected by conflict and instability. Traditionally, Somalia has faced challenges from communicable diseases, but the landscape is shifting. NCDs now contribute to roughly 30% of premature mortality in the nation. This desk review explores the prevalence of these diseases, the governance challenges that exist, and the opportunities for enhancing health system responses to the increasing burden of NCDs in Somalia. Methodology The methodology implemented a dual-modal search strategy to ensure maximal evidence capture. First, we performed a systematic sweep of the academic landscape using key platforms: PubMed, Scopus, and Google Scholar. Second, we conducted a parallel review of crucial grey literature, actively seeking policy documents and national reports from organizations like the WHO and the Somali Ministry of Health. Only material published in English within the past ten years, and specific to NCDs in Somalia, was deemed eligible. Following data extraction, the information was thematically consolidated and rigorously appraised, with each source’s quality being judged by its underlying study methodology and organizational authority. Results NCDs account for approximately 30% of premature deaths in Somalia. Hypertension (33%) and diabetes (20%) being the most prevalent. Women, urban residents, older adults, and wealthier individuals report higher prevalence. Challenges include a fragile health system, with only 29% of facilities offering cardiovascular and diabetes services, a severe shortage of skilled health workers, and limited diagnostic and treatment capacity. Recurrent humanitarian crises exacerbate NCD risk factors and disrupt care. Opportunities include leveraging community health worker programs, engaging the Somali diaspora, and adapting WHO’s Package of Essential NCD Interventions (PEN). The ongoing development of the national NCD policy signals progress. Conclusion The escalation of NCDs in Somalia demands urgent, coordinated efforts. The primary recommendations for action include: fully implementing the national NCD policy, integrating NCD treatment into primary healthcare, scaling up Community Health Worker (CHW) capabilities, and increasing the mobilization of the diaspora. Success hinges on adapting interventions locally and ensuring a multi-sectoral response is sustained to effectively improve public health and contribute to Sustainable Development Goal 3 (SDG 3) attainment. Health Economics & Outcomes Research Health Policy Health Law Non-Communicable diseases Health equity Public health policy NCD governance fragile states health system strengthening integrated healthcare systems Sustainable Development Goals. INTRODUCTION Non-Communicable diseases (NCDs) represent a significant and growing global health crisis, posing a substantial threat to human well-being and socioeconomic development worldwide [ 1 – 3 ]. These chronic conditions, which include cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes, are the leading causes of mortality globally [ 4 ]. The primary drivers behind the escalating NCD burden are modifiable behavioral risk factors, notably tobacco use, unhealthy diets, insufficient physical activity, and the harmful consumption of alcohol [ 5 – 9 ]. While these risk factors are universally applicable, their prevalence and impact manifest differently across diverse populations and settings, necessitating context-specific approaches to prevention and control. Low- and middle-income countries (LMICs) bear a disproportionately high burden of the global NCD epidemic, accounting for approximately 73% of all NCD-related deaths [ 2 , 10 ]. Within this group, fragile, conflict-affected and violent states (FCVs) face a particularly complex and challenging scenario. These nations often grapple with protracted conflicts, political instability, weak governance structures, and severely compromised health systems characterized by limited infrastructure, inadequate human resources, and chronic underfunding [ 11 – 14 ]. The persistent impact of humanitarian crises, including displacement, food insecurity, and natural disasters, further compounds the challenges of addressing long-term health concerns such as NCDs. In these settings, the immediate priorities of humanitarian aid often overshadow the critical need for sustained attention and resources dedicated to preventing and managing chronic diseases. The intricate interplay between fragility, humanitarian crises, and the rising prevalence of NCDs creates a vicious cycle that demands urgent and comprehensive interventions [ 15 – 21 ]. Somalia, a country marked by decades of civil conflict, political fragmentation, and recurrent humanitarian emergencies, is now confronting a rapidly growing epidemic of NCDs alongside persistently high rates of communicable diseases [ 22 , 23 ]. Historically, infectious diseases, maternal and child health issues, and nutritional deficiencies have been the primary causes of morbidity and mortality in Somalia [ 24 ]. However, recent evidence indicates a significant epidemiological transition, with NCDs now accounting for a substantial proportion of the overall disease burden. In 2022, it was estimated that NCDs were responsible for approximately 30% of premature deaths in Somalia, a figure considerably higher than the Eastern Mediterranean region (23%) for the same period [ 25 – 27 ]. This alarming statistic underscores that NCDs are no longer a peripheral health concern but have become a major public health imperative in Somalia, demanding immediate and sustained attention from policymakers, healthcare providers, and the international community. This desk review aims to comprehensively analyze the prevalence, address the challenges and facilitators to effective NCD governance and leadership, identify opportunities within the healthcare system, formulate strategic recommendations to strengthen NCD governance and leadership. This will provide valuable insights for policymakers, healthcare practitioners, researchers, and development partners working to combat the growing threat of NCDs in Somalia and improve the health and well-being of the Somali population. METHODOLOGY Executed as a systematic narrative synthesis , this review was designed for the complex task of appraising evidence related to Non-Communicable Disease (NCD) governance and health system endurance in Somalia. The methodology adopted a rigorous, multi-phase structure to ensure a comprehensive and context-aware consolidation of all relevant information. Study Design and Scope The study design focused on synthesizing both quantitative and qualitative data. The primary objective was to move beyond simple prevalence reporting to critically analyze the underlying systemic and governance challenges, and to identify feasible, context-specific strategic opportunities for intervention. The review was strictly constrained to information specific to Somalia or highly analogous low-resource, conflict-affected settings, ensuring the final recommendations are grounded in relevant realities. Information Retrieval and Search Strategy A comprehensive, dual-modal search strategy was implemented across both peer-reviewed and grey literature to maximize coverage of available evidence. Academic Database Search Major bibliographic databases, including PubMed , Scopus , and Google Scholar , were systematically queried to retrieve peer-reviewed research articles, systematic reviews, and meta-analyses. The search queries were constructed using Boolean operators to combine three core thematic domains: Disease : ("Non-Communicable diseases" OR "NCD") Geography/Context : ("Somalia" OR "fragile states") Focus Areas : ("governance" OR "leadership" OR "policy" OR "intervention" OR "risk factors" OR "prevalence") Grey Literature and Policy Review Concurrently, an extensive review of policy-relevant grey literature was conducted. This targeted high-impact reports from official bodies, including the World Health Organization (WHO) , the Federal Ministry of Health of Somalia , the United Nations Children's Fund (UNICEF) , the International Organization for Migration (IOM) , and the NCD Alliance . Specific emphasis was placed on locating national strategic health plans, comprehensive national survey reports (e.g., the Somali Health and Demographic Survey), and organizational reports detailing the impact of humanitarian crises on health outcomes. Eligibility Criteria and Screening Process All identified literature and reports were screened based on predefined, rigorous eligibility criteria: Inclusion Criteria : Publications were included if they provided quantitative or qualitative data directly relevant to NCD prevalence, risk factors, policy, governance, system challenges, or interventions specific to Somalia or highly analogous contexts. Furthermore, inclusion was strictly limited to English-language publications and those published within the last decade (2015 onwards) to ensure temporal relevance. Exclusion Criteria : Studies or reports were excluded if they focused solely on communicable diseases, discussed general health issues without specific NCD components, or presented only regional data without explicit, granular information relevant to Somalia or its unique governance setting. Data Charting, Extraction, and Thematic Synthesis Data extraction was meticulously performed using a standardized data charting form . This form was designed to capture essential information from each source, including: NCD prevalence rates, associated mortality figures, documented risk factors, status of existing policies/strategies, identified health system bottlenecks, and specific intervention opportunities. The retrieved evidence was then subjected to a thematic synthesis . This process involved: Grouping : Categorizing similar findings related to the research objectives (e.g., all data on "Hypertension Prevalence" or "Human Resource Shortages"). Pattern Identification : Analyzing the grouped information to establish recurring patterns, common challenges, contradictions in findings, and critical insights. Narrative Construction : Synthesizing the thematic findings into a coherent narrative that directly addresses the research questions and forms the evidence base for the Discussion and Recommendations sections. Assessment of Evidence Quality A focused, pragmatic quality appraisal was integrated into the review process. Given the diversity of sources inherent in a desk review of a fragile state, two distinct approaches were utilized: Peer-Reviewed Literature : Academic articles were assessed for methodological rigor , including the appropriateness of the study design, the adequacy of the sample size, and the robustness of the statistical analysis employed. Grey Literature : Institutional and policy reports were judged based on the credibility and authority of the issuing organization (e.g., UN agencies, recognized NGOs, or government ministries) and the transparency of their data generation methodology, ensuring the final synthesis relies on the most authoritative available evidence. RESULTS Prevalence and Impact of NCDs in Somalia The 2020 Somali Health and Demographic Survey (SHDS) provides the most comprehensive national-level data on the prevalence of chronic conditions among adults in Somalia. The survey revealed that approximately 6% of the population reported being diagnosed with at least one chronic condition [ 28 ]. Among the specific conditions, hypertension emerged as the most prevalent, affecting a substantial 33% of the adult population. This high prevalence of hypertension underscores the significant burden of cardiovascular risk factors in Somalia. Diabetes was the second most reported condition, with a prevalence of 20%. Arthritis affected 8% of adults, highlighting the growing challenge of metabolic disorders in the country. Kidney disease was reported by 8% of the adult population. Other NCDs identified in the SHDS included chronic back pain (5.1%), chronic headache (7.1%), cancer (0.7%), Asthma (6.2%), heart disease (5.4%), stomach/peptic ulcer (5.9%), Chronic mental/psychological illnesses (6.5%) [ 28 ]. A 2022 Somali Integrated Household budget survey on chronic illnesses in Somalia reflected absence of gender disparities in hypertension at 26.3%. However, males being more prone to diabetes compared to females, while females were more likely to report joint inflammation [ 29 ]. The review has highlighted that the impact of NCDs on mortality in Somalia is substantial and increasing. In 2022, NCDs were estimated to account for 30% of all deaths in the country [ 27 ]. The leading NCDs include cardiovascular diseases, with hypertensive heart disease being the most prevalent (39.8%), followed by valvular heart disease (34.6%), and heart failure (30.8%) [ 30 ]. Among cancers, esophageal cancer is the most common (21.7%), followed by liver cancer (7.6%), and breast cancer (7.3%) [ 31 ]. Diabetes is also likely to be major contributors to this high burden in Somalia, although specific mortality data for each NCD category was not readily available in the reviewed materials [ 32 ]. The SHDS data also revealed significant socio-demographic disparities in the prevalence of chronic conditions. Women reported a higher overall prevalence of chronic diseases compared to men (7% versus 5%). Urban residents had a higher prevalence (7%) than those living in rural and nomadic areas (5% and 4% respectively), potentially reflecting differences in lifestyle, access to healthcare, and awareness of chronic conditions. Age was a strong predictor of chronic disease, with prevalence increasing dramatically from 7% among young adults aged 20–24 years to 20% among those aged 70 years and older. Furthermore, individuals with higher levels of education (secondary or higher) and greater wealth status were more likely to report having a chronic disease [ 28 ]. This could be attributed to better access to diagnosis and healthcare services among these groups, or potentially to lifestyle factors associated with higher socioeconomic status. Data published by WHO also provides critical data on Non-Communicable disease (NCD) risk factors and mortality in Somalia, highlighting the growing burden of chronic conditions. In 2022, the probability of premature mortality (between ages 30 and 70 years) from NCDs was estimated from 24% in 2016 to 30% in 2022 for both males and females, indicating a significant public health challenge. Raised blood pressure (hypertension) was prevalent among 33% of adults aged 30–79 years in 2022, underscoring a major cardiovascular risk factor. Obesity prevalence among adults aged 18 and older was estimated at 7% in 2016; however, recent trends show an increase, reaching 15% in 2022, with an annual rise of 0.6 percentage points between 2021 and 2022. The mean salt intake among adults aged 20 and older increased from 5 g/day in 2016 to 7 g/day in 2022, exceeding WHO-recommended levels and contributing to hypertension risk. Physical inactivity among adults aged 18 and older was reported at 18% in 2022, reflecting a sedentary lifestyle trend [ 27 ]. In Somaliland, tobacco use was reported at 27% and khat use at 37% among adults in 2022, based on regional data, highlighting significant behavioral risk factors for NCDs [ 33 ]. Key NCD progress indicators status in Somalia and EMRO region NO indicators Somalia EMRO Region African Region 1 Probability of premature mortality from NCDs (2019) 29% 23% 21% 2 Percentage of total deaths due to NCDs (2019) 28% 63% 37% 3 Percentage of NCD deaths occurring under 70 years (2019) 72% 56% 61% 4 NCD age-standardized death rate (2019) 816 per 100 000 population 624 per 100 000 population 595 per 100 000 population 5 Mortality rate attributed to household and ambient air pollution (2019) 238 per 100 000 population 136 per 100 000 population 163 per 100 000 population 6 Population with primary reliance on polluting fuels and technologies (2020) 97% (95% in urban and 100% in rural) 27% (urban 8% and rural = 47%) 80% (61% in urban and 94% in rural) 7 Cancer age-standardized death rate (2019) 129 per 100 000 population 105 per 100 000 population 123 per 100 000 population 8 Total cancer deaths (2019) 8583 484966 665188 9 CRD age-standardized death rate (2019) 68 per 100 000 population 42 per 100 000 population 37 per 100 000 population 10 CVD age-standardized death rate (2019) 315 per 100 000 population 329 per 100 000 population 255 per 100 000 population 11 Diabetes age-standardized death rate (2019) 59 per 100 000 population 32 per 100 000 population 40 per 100 000 population 12 Percentage of diabetes deaths occurring under 70 years (2019) 63% 55% 56% NCD risk factors Raised fasting blood glucose, adults aged 18+ (2014) 7% 14% Overweight, adults aged 18 + and adolescents (2022) 35% (21% male and 49% female) 60% and 27% respectively 31% (24% male and 39% female) Obesity, adults aged 18 + and adolescents (2022) 15% 29% and 11% respectively 12% Obesity among adolescents aged 10–19 (2022) 3% 11% 3% Mean population salt intake, adults aged 25+ (2019) 7g / day 7g / day 7g/day Physical inactivity among adults (18+) or adolescents (11–17 years) (2022) 18% among adults with no data among adolescents 40% among adults and 87% among adolescents 17% among adults and 85% among adolescents Current tobacco use, adults aged 15+ (2022) No data 18% 10% Source: WHO EMRO NCD data portal [ 26 ] Challenges in integrating NCD services into the primary system Somalia's history of protracted conflict and ongoing fragility has severely damaged its healthcare infrastructure, compromising access to essential health services, particularly for the long-term management of chronic conditions [ 34 ]. The scarcity of trained healthcare professionals, including physicians, nurses, and allied health workers with expertise in NCDs, further exacerbates these challenges, hindering the provision of adequate and specialized care for individuals living with these diseases. Somalia’s HRH index stands less than 1 skilled health workers per 1000 population, below the WHO recommended 2.3 skilled health worker per 1000 population [ 35 ]. Urban hospitals have more doctors and nurses than rural facilities, but specialized NCD personnel, including specialist physicians, diabetic/psychiatric nurses, community health workers, and nutritionists, are largely absent. Health facility capacity for NCD management is severely limited, as revealed by the 2023 Harmonized Health Facility Assessment (HHFA). Only 29% of facilities offer cardiovascular and diabetes services, 24% for asthma, 16% for chronic obstructive pulmonary disease, 12% for mental health, and 6% for cancer. Primary Health Units provide minimal NCD services, with only 3% offering hypertension, diabetes, or asthma management, while public hospitals offer higher coverage, such as 57% for cardiovascular disease and 54% for diabetes. Cancer services are limited, even in private specialty hospitals at 20% [ 36 ]. Facility readiness is inadequate, with aspirin available in 67% of facilities but fewer than 50% having calcium channel blockers, beta-blockers, or statins. Metformin is available in 62% of facilities, injectable glucose in 60%, and insulin in 47%. Diagnostic tests for diabetes are available in less than 40% of health centers and 25% of Primary Health Units [ 36 ]. Cancer screening and treatment are nearly absent. Advanced diagnostics, such as echography and CT, MRI and PET scanners, are lacking in major public facilities, and available equipment is often non-functional due to a lack of expertise [ 37 ]. Essential NCD tools, including monofilaments and spirometers, are absent, and reliance on paper records hinders data collection. Laboratories lack capacity for specific NCD tests, such as urine macro albumin and cancer diagnostics, with inadequate reagent storage compromising test reliability. Advanced tests like hemoglobin electrophoresis are unavailable. Public hospitals lack dedicated NCD clinics, and diagnostic services, including BMI calculation, eye exams, and cancer screening, are limited. Palliative care, chemotherapy, and radiotherapy are absent in public facilities. First-line drugs for hypertension and diabetes are available, but second-line drugs and anticancer medications are scarce. Guidelines for diabetes and hypertension exist, but those for cancer, mental health, and palliative care are lacking. Few hospitals have formal referral protocols, and community NCD education is minimal, limiting prevention and follow-up [ 36 ]. Financial constraints and the need to address competing health priorities, such as infectious diseases, maternal and child health, and emergency response, often lead to insufficient allocation of resources towards NCD prevention and control programs. This resource-limited environment makes it difficult to establish and sustain effective long-term NCD programs, necessitating the development of innovative and cost-effective solutions [ 38 – 40 ] The frequent humanitarian crises that affect Somalia, including conflict-induced displacement, recurrent droughts leading to food insecurity, and other natural disasters, have a significant and multifaceted impact on the rising burden of NCDs [ 41 , 42 ]. Displacement can disrupt the continuity of care for individuals already diagnosed with NCDs, leading to potential complications and poorer health outcomes due to lack of access to medication, regular check-ups, and specialized services [ 38 , 43 ]. Humanitarian emergencies can also exacerbate key NCD risk factors, such as poor dietary habits resulting from food shortages, increased levels of stress due to insecurity and displacement, and further reduced access to already strained healthcare services [ 44 – 46 ]. The immediate focus on life-saving interventions during these crises may inadvertently overshadow the longer-term healthcare needs of individuals living with NCDs. Moreover, the experience of trauma and displacement can increase the risk of mental health disorders, which are increasingly recognized as important NCDs or risk factors for other NCDs [ 47 , 48 ]. The cyclical nature of humanitarian crises in Somalia can create a detrimental feedback loop, where NCDs are both aggravated by the crises and, in turn, hinder recovery efforts due to increased morbidity and mortality within the affected population [ 42 ]. While the Somali Federal Ministry of Health (FMoH) has acknowledged the increasing threat of NCDs and is taking steps to address them, there may still be gaps in the comprehensiveness and effective implementation of national health policies, strategies, and specific action plans targeting NCD prevention and control [ 49 , 50 ]. The Health Sector Strategic Plan 2022–2026 (HSSP III) recognizes the growing burden of NCDs and includes them as one of its key priority areas, highlighting mental health, diabetes, and hypertension as major neglected conditions [ 49 ]. The revised Essential Package of Health Services (EPHS) 2020 also includes NCDs as one of its six key areas, focusing on health promotion and disease prevention, cardiovascular and pulmonary diseases, diabetes, cancer, mental health and substance use disorders, injuries, and other NCDs [ 51 – 53 ]. The ongoing development of the first national NCD policy and strategy, with support from international organizations, signals a growing recognition of the need for a more structured and comprehensive approach to NCD governance and leadership in Somalia. This policy aims to strengthen the governance capabilities of the FMoH and create multi-sectoral steering committees at both national and sub-national levels [ 22 ]. Sociocultural factors and stigma surrounding NCDs can also pose challenges to effective governance and individual health-seeking behaviors in Somalia. Awareness of NCD risk factors and the importance of early detection and management are limited in some communities. Traditional beliefs and practices may influence health behaviors and access to formal healthcare services for NCDs [ 54 ]. Addressing these sociocultural barriers through culturally appropriate health education and community engagement strategies is crucial for improving NCD prevention and control efforts. Enablers and Opportunities for Strengthening NCD Governance and leadership Despite the significant challenges, Somalia possesses certain healthcare infrastructures and potential resources that can be leveraged to strengthen NCD governance and improve the health outcomes of its population [ 43 ]. The strong Community health worker (CHW) programme represents a particularly valuable asset in Somalia's healthcare system, acting as a vital link between communities and the formal health system [ 55 ]. These programmes have the potential to play a crucial role in NCD prevention by raising awareness about risk factors and promoting healthy lifestyles [ 55 – 57 ]. CHWs can also contribute to early detection through community-based screening initiatives and facilitate access to care by referring individuals with suspected NCDs to health facilities. Furthermore, CHWs can support community-level management of NCDs by providing health education, medication adherence support, and follow-up care, especially in underserved and remote areas where access to formal healthcare facilities is limited [ 58 – 61 ]. Integrating NCD-focused interventions into the existing primary healthcare system, as outlined in the Essential Package of Health Services (EPHS) 2020, offers a significant opportunity to reach a broader segment of the population with essential NCD services [ 51 ]. Enhancing the capacity of CHWs to address NCDs through targeted training, providing them with the necessary tools and resources, and ensuring their effective integration into the primary healthcare network could be a cost-effective and sustainable strategy to improve access to NCD care in Somalia's resource-constrained environment. The sizable Somali diaspora represents another crucial resource that can be strategically mobilized to support the health sector in Somalia, including in the critical area of NCDs. The diaspora possesses a wealth of expertise, skills, and financial resources that can be channeled towards strengthening healthcare systems and addressing specific health challenges. Initiatives such as the Migration for Development in Africa (MIDA) FINNSOM project have successfully demonstrated the potential of engaging diaspora professionals in contributing to policy development, capacity building within health institutions, and improving the delivery of essential health services, including in the area of NCDs [ 62 , 63 ]. Furthermore, numerous diaspora organizations are actively involved in providing direct healthcare services, donating medical supplies, and supporting health-related initiatives within Somalia. Actively fostering partnerships and developing targeted programs to effectively engage the Somali diaspora can provide much-needed technical expertise, financial support, and innovative solutions to combat the growing burden of NCDs in the country [ 64 , 65 ]. Learning from the experiences of other low-resource settings and countries that share similar socio-economic and political contexts with Somalia can provide valuable insights and adaptable models for successful NCD prevention and management [ 66 – 68 ]. The World Health Organization (WHO) Package of Essential Noncommunicable Disease Interventions (WHO PEN) for primary care in low-resource settings offers a prioritized set of cost-effective interventions that have been designed for implementation even in resource-poor environments [ 69 ]. These interventions focus on early detection, treatment, and management of major NCDs at the primary care level. Strategies such as task-shifting specific NCD care responsibilities to community health workers and leveraging the increasing accessibility of mobile health (mHealth) interventions have shown promising results in improving NCD care delivery and management in various LMICs [ 70 – 72 ]. Adapting exercise-based rehabilitation programs for NCDs to low-resource settings by training non-conventional health workers and integrating rehabilitation into community health centers has also demonstrated feasibility [ 73 , 74 ]. By carefully examining and adapting evidence-based interventions that have proven successful in comparable settings, Somalia can potentially accelerate its progress in addressing NCDs, saving valuable time and limited resources by building upon existing knowledge and best practices. DISCUSSION AND RECOMMENDATIONS The findings of this desk review highlight the significant and growing burden of NCDs in Somalia, evidenced by the high prevalence of conditions like hypertension and diabetes and their substantial contribution to overall morbidity and mortality [ 25 , 75 ]. This epidemiological shift necessitates a fundamental change in the approach to healthcare, moving beyond a primary focus on communicable diseases and maternal and child health to integrate comprehensive NCD prevention and management strategies [ 38 , 76 ]. The complex interplay of a fragile health system, recurrent humanitarian crises, and diverse socio-demographic factors creates a particularly challenging environment for effective NCD governance and leadership [ 39 , 43 ]. The growing prevalence of chronic conditions among women, urban residents, older adults, and those with higher socioeconomic status underscores the need for targeted interventions that address these specific population groups. For instance, interventions in urban areas might focus on promoting healthy diets and physical activity in the face of changing lifestyles, while efforts targeting older adults need to address the increasing multimorbidity associated with aging. The higher prevalence among wealthier and more educated individuals might reflect better access to diagnosis, but it also suggests a need to understand the behavioral and environmental factors driving NCDs in these groups [ 28 , 29 ]. Lessons from successful NCD interventions in low-resource settings provides valuable guidance for adapting evidence-based approaches in Somalia. Specifically, Somalia should integrate NCD prevention and management into its primary healthcare system, drawing inspiration from the effective implementation of the World Health Organization’s Package of Essential Noncommunicable Disease Interventions (WHO PEN) in Nepal, Myanmar and Indonesia. In these countries, which face resource constraints and histories of political instability similar to Somalia, WHO PEN was implemented in primary health centers to address cardiovascular diseases and diabetes. By training non-specialist health workers, including community health workers (CHWs), to conduct basic screenings, deliver lifestyle counseling, and manage essential medications such as metformin and antihypertensives, Nepal, Myanmar and Indonesia enhanced access to NCD care, improving screening, diagnosis, treatment, and follow-up in underserved areas. For Somalia, where only 29% of health facilities offer cardiovascular and diabetes services, integrating WHO PEN into the Essential Package of Health Services (EPHS) 2020 could strengthen NCD management, provided investments are made in training, diagnostic tools, and reliable drug supply chains to address the country’s fragile health infrastructure and frequent humanitarian disruptions [ 77 – 79 ]. To strengthen care delivery within Somalia’s fragmented health system, mobile health (mHealth) technologies present a transformative opportunity, as evidenced by their success in low-resource and conflict-affected settings globally. In DRC, Cambodia and the Philippines, mHealth platforms have enabled SMS reminders for diabetes medication adherence and remote patient monitoring, improving outcomes in underserved regions [ 80 ]. Somalia, where paper-based records impede data collection and conflict frequently disrupts connectivity, could adopt low-cost, offline-capable mHealth solutions to track patients with chronic conditions, such as hypertension, and deliver education on risk factors. Integrating NCD indicators into Somalia’s existing District Health Information System 2 (DHIS2), already used for health data recording and decision-making, could enhance monitoring of NCD prevalence, treatment outcomes, and service gaps, as demonstrated in Bangladesh, where DHIS2 integration improved data-driven decision-making for hypertension data [ 81 ]. However, experiences from other conflict-affected states underscore the need for reliable technical support, and robust data protection to sustain mHealth programs [ 82 , 83 ]. Somalia must prioritize offline-compatible mHealth tools, train local staff to maintain systems, and address low community awareness and stigma around NCDs to ensure adoption. Community engagement is another vital strategy, inspired by successful models in low- and middle-income countries, where community empowerment has addressed NCD concerns [ 84 – 88 ]. Somalia can engage communities through culturally sensitive campaigns, leveraging local leaders to counter traditional beliefs that deter health-seeking behavior. The Somali diaspora, a unique asset, can amplify these efforts, as seen in the MIDA FINNSOM project, which mobilized diaspora expertise to strengthen health systems. By involving diaspora professionals in training CHWs or funding community health initiatives, Somalia can enhance NCD education and service delivery. The ongoing development of a national NCD policy and strategy is a critical step towards establishing a more robust and coordinated framework for addressing the growing NCD burden in Somalia. This policy needs to be comprehensive, multi-sectoral, and aligned with the existing Health Sector Strategic Plan and global best practices. Effective implementation of this policy, with clear targets, allocated resources, and robust monitoring and evaluation mechanisms, will be crucial for achieving meaningful progress in NCD prevention and control. Conclusion Somalia is facing a significant and escalating crisis of non-communicable diseases that demands urgent and concerted action from all stakeholders. While the country grapples with numerous challenges, including a fragile health system, recurrent humanitarian emergencies, and limited resources, there are also notable enablers and opportunities that can be leveraged to strengthen NCD governance and leadership. This desk review underscores the critical need for a comprehensive and multi-sectoral approach to address the rising burden of NCDs in Somalia. Key strategic recommendations include strengthening the integration of NCD services into the primary healthcare system, enhancing the capacity of community health workers to address NCDs, actively engaging the Somali diaspora in NCD prevention and control efforts, learning from successful interventions in similar settings and finalizing and effectively implementing the national NCD policy and strategy. Addressing the growing epidemic of NCDs is essential for improving the health and well-being of the Somali population and for achieving the Sustainable Development Goals, particularly SDG 3. Sustained commitment, investment, and collaboration among all stakeholders are crucial to navigate this crisis and build a healthier future for Somalia. References Bennett JE, Stevens GA, Mathers CD, Bonita R, Rehm J, Kruk ME et al (2018) NCD Countdown 2030: worldwide trends in non-communicable disease mortality and progress towards Sustainable Development Goal target 3.4. 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Somalia\u003cbr\u003e\n\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eNon-Communicable diseases (NCDs) represent a significant and growing global health crisis, posing a substantial threat to human well-being and socioeconomic development worldwide [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. These chronic conditions, which include cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes, are the leading causes of mortality globally [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe primary drivers behind the escalating NCD burden are modifiable behavioral risk factors, notably tobacco use, unhealthy diets, insufficient physical activity, and the harmful consumption of alcohol [\u003cspan additionalcitationids=\"CR6 CR7 CR8\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. While these risk factors are universally applicable, their prevalence and impact manifest differently across diverse populations and settings, necessitating context-specific approaches to prevention and control.\u003c/p\u003e\u003cp\u003eLow- and middle-income countries (LMICs) bear a disproportionately high burden of the global NCD epidemic, accounting for approximately 73% of all NCD-related deaths [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Within this group, fragile, conflict-affected and violent states (FCVs) face a particularly complex and challenging scenario. These nations often grapple with protracted conflicts, political instability, weak governance structures, and severely compromised health systems characterized by limited infrastructure, inadequate human resources, and chronic underfunding [\u003cspan additionalcitationids=\"CR12 CR13\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe persistent impact of humanitarian crises, including displacement, food insecurity, and natural disasters, further compounds the challenges of addressing long-term health concerns such as NCDs. In these settings, the immediate priorities of humanitarian aid often overshadow the critical need for sustained attention and resources dedicated to preventing and managing chronic diseases. The intricate interplay between fragility, humanitarian crises, and the rising prevalence of NCDs creates a vicious cycle that demands urgent and comprehensive interventions [\u003cspan additionalcitationids=\"CR16 CR17 CR18 CR19 CR20\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSomalia, a country marked by decades of civil conflict, political fragmentation, and recurrent humanitarian emergencies, is now confronting a rapidly growing epidemic of NCDs alongside persistently high rates of communicable diseases [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Historically, infectious diseases, maternal and child health issues, and nutritional deficiencies have been the primary causes of morbidity and mortality in Somalia [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eHowever, recent evidence indicates a significant epidemiological transition, with NCDs now accounting for a substantial proportion of the overall disease burden. In 2022, it was estimated that NCDs were responsible for approximately 30% of premature deaths in Somalia, a figure considerably higher than the Eastern Mediterranean region (23%) for the same period [\u003cspan additionalcitationids=\"CR26\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. This alarming statistic underscores that NCDs are no longer a peripheral health concern but have become a major public health imperative in Somalia, demanding immediate and sustained attention from policymakers, healthcare providers, and the international community.\u003c/p\u003e\u003cp\u003eThis desk review aims to comprehensively analyze the prevalence, address the challenges and facilitators to effective NCD governance and leadership, identify opportunities within the healthcare system, formulate strategic recommendations to strengthen NCD governance and leadership. This will provide valuable insights for policymakers, healthcare practitioners, researchers, and development partners working to combat the growing threat of NCDs in Somalia and improve the health and well-being of the Somali population.\u003c/p\u003e"},{"header":"METHODOLOGY","content":"\u003cp\u003eExecuted as a \u003cb\u003esystematic narrative synthesis\u003c/b\u003e, this review was designed for the complex task of appraising evidence related to \u003cb\u003eNon-Communicable Disease (NCD) governance\u003c/b\u003e and health system endurance in Somalia. The methodology adopted a rigorous, multi-phase structure to ensure a comprehensive and context-aware consolidation of all relevant information.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design and Scope\u003c/h2\u003e\u003cp\u003eThe study design focused on synthesizing both quantitative and qualitative data. The primary objective was to move beyond simple prevalence reporting to critically analyze the underlying systemic and governance challenges, and to identify feasible, context-specific strategic opportunities for intervention. The review was strictly constrained to information specific to Somalia or highly analogous low-resource, conflict-affected settings, ensuring the final recommendations are grounded in relevant realities.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eInformation Retrieval and Search Strategy\u003c/h3\u003e\n\u003cp\u003eA comprehensive, dual-modal search strategy was implemented across both peer-reviewed and grey literature to maximize coverage of available evidence.\u003c/p\u003e\n\u003ch3\u003eAcademic Database Search\u003c/h3\u003e\n\u003cp\u003eMajor bibliographic databases, including \u003cb\u003ePubMed\u003c/b\u003e, \u003cb\u003eScopus\u003c/b\u003e, and \u003cb\u003eGoogle Scholar\u003c/b\u003e, were systematically queried to retrieve peer-reviewed research articles, systematic reviews, and meta-analyses. The search queries were constructed using Boolean operators to combine three core thematic domains:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eDisease\u003c/b\u003e: (\"Non-Communicable diseases\" OR \"NCD\")\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eGeography/Context\u003c/b\u003e: (\"Somalia\" OR \"fragile states\")\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eFocus Areas\u003c/b\u003e: (\"governance\" OR \"leadership\" OR \"policy\" OR \"intervention\" OR \"risk factors\" OR \"prevalence\")\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\n\u003ch3\u003eGrey Literature and Policy Review\u003c/h3\u003e\n\u003cp\u003eConcurrently, an extensive review of policy-relevant grey literature was conducted. This targeted high-impact reports from official bodies, including the \u003cb\u003eWorld Health Organization (WHO)\u003c/b\u003e, the \u003cb\u003eFederal Ministry of Health of Somalia\u003c/b\u003e, the \u003cb\u003eUnited Nations Children's Fund (UNICEF)\u003c/b\u003e, the \u003cb\u003eInternational Organization for Migration (IOM)\u003c/b\u003e, and the \u003cb\u003eNCD Alliance\u003c/b\u003e. Specific emphasis was placed on locating national strategic health plans, comprehensive national survey reports (e.g., the Somali Health and Demographic Survey), and organizational reports detailing the impact of humanitarian crises on health outcomes.\u003c/p\u003e\n\u003ch3\u003eEligibility Criteria and Screening Process\u003c/h3\u003e\n\u003cp\u003eAll identified literature and reports were screened based on predefined, rigorous eligibility criteria:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eInclusion Criteria\u003c/b\u003e: Publications were included if they provided quantitative or qualitative data directly relevant to NCD prevalence, risk factors, policy, governance, system challenges, or interventions specific to Somalia or highly analogous contexts. Furthermore, inclusion was strictly limited to English-language publications and those published within the last decade (2015 onwards) to ensure temporal relevance.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eExclusion Criteria\u003c/b\u003e: Studies or reports were excluded if they focused solely on communicable diseases, discussed general health issues without specific NCD components, or presented only regional data without explicit, granular information relevant to Somalia or its unique governance setting.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eData Charting, Extraction, and Thematic Synthesis\u003c/h2\u003e\u003cp\u003eData extraction was meticulously performed using a standardized \u003cb\u003edata charting form\u003c/b\u003e. This form was designed to capture essential information from each source, including: NCD prevalence rates, associated mortality figures, documented risk factors, status of existing policies/strategies, identified health system bottlenecks, and specific intervention opportunities.\u003c/p\u003e\u003cp\u003eThe retrieved evidence was then subjected to a \u003cb\u003ethematic synthesis\u003c/b\u003e. This process involved:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eGrouping\u003c/b\u003e: Categorizing similar findings related to the research objectives (e.g., all data on \"Hypertension Prevalence\" or \"Human Resource Shortages\").\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003ePattern Identification\u003c/b\u003e: Analyzing the grouped information to establish recurring patterns, common challenges, contradictions in findings, and critical insights.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eNarrative Construction\u003c/b\u003e: Synthesizing the thematic findings into a coherent narrative that directly addresses the research questions and forms the evidence base for the Discussion and Recommendations sections.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eAssessment of Evidence Quality\u003c/h3\u003e\n\u003cp\u003eA focused, pragmatic quality appraisal was integrated into the review process. Given the diversity of sources inherent in a desk review of a fragile state, two distinct approaches were utilized:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003ePeer-Reviewed Literature\u003c/b\u003e: Academic articles were assessed for \u003cb\u003emethodological rigor\u003c/b\u003e, including the appropriateness of the study design, the adequacy of the sample size, and the robustness of the statistical analysis employed.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eGrey Literature\u003c/b\u003e: Institutional and policy reports were judged based on the \u003cb\u003ecredibility and authority\u003c/b\u003e of the issuing organization (e.g., UN agencies, recognized NGOs, or government ministries) and the transparency of their data generation methodology, ensuring the final synthesis relies on the most authoritative available evidence.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003ePrevalence and Impact of NCDs in Somalia\u003c/h2\u003e\u003cp\u003eThe 2020 Somali Health and Demographic Survey (SHDS) provides the most comprehensive national-level data on the prevalence of chronic conditions among adults in Somalia. The survey revealed that approximately 6% of the population reported being diagnosed with at least one chronic condition [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAmong the specific conditions, hypertension emerged as the most prevalent, affecting a substantial 33% of the adult population. This high prevalence of hypertension underscores the significant burden of cardiovascular risk factors in Somalia. Diabetes was the second most reported condition, with a prevalence of 20%. Arthritis affected 8% of adults, highlighting the growing challenge of metabolic disorders in the country. Kidney disease was reported by 8% of the adult population. Other NCDs identified in the SHDS included chronic back pain (5.1%), chronic headache (7.1%), cancer (0.7%), Asthma (6.2%), heart disease (5.4%), stomach/peptic ulcer (5.9%), Chronic mental/psychological illnesses (6.5%) [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eA 2022 Somali Integrated Household budget survey on chronic illnesses in Somalia reflected absence of gender disparities in hypertension at 26.3%. However, males being more prone to diabetes compared to females, while females were more likely to report joint inflammation [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe review has highlighted that the impact of NCDs on mortality in Somalia is substantial and increasing. In 2022, NCDs were estimated to account for 30% of all deaths in the country [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The leading NCDs include cardiovascular diseases, with hypertensive heart disease being the most prevalent (39.8%), followed by valvular heart disease (34.6%), and heart failure (30.8%) [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Among cancers, esophageal cancer is the most common (21.7%), followed by liver cancer (7.6%), and breast cancer (7.3%) [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Diabetes is also likely to be major contributors to this high burden in Somalia, although specific mortality data for each NCD category was not readily available in the reviewed materials [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe SHDS data also revealed significant socio-demographic disparities in the prevalence of chronic conditions. Women reported a higher overall prevalence of chronic diseases compared to men (7% versus 5%). Urban residents had a higher prevalence (7%) than those living in rural and nomadic areas (5% and 4% respectively), potentially reflecting differences in lifestyle, access to healthcare, and awareness of chronic conditions. Age was a strong predictor of chronic disease, with prevalence increasing dramatically from 7% among young adults aged 20–24 years to 20% among those aged 70 years and older. Furthermore, individuals with higher levels of education (secondary or higher) and greater wealth status were more likely to report having a chronic disease [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. This could be attributed to better access to diagnosis and healthcare services among these groups, or potentially to lifestyle factors associated with higher socioeconomic status.\u003c/p\u003e\u003cp\u003eData published by WHO also provides critical data on Non-Communicable disease (NCD) risk factors and mortality in Somalia, highlighting the growing burden of chronic conditions. In 2022, the probability of premature mortality (between ages 30 and 70 years) from NCDs was estimated from 24% in 2016 to 30% in 2022 for both males and females, indicating a significant public health challenge. Raised blood pressure (hypertension) was prevalent among 33% of adults aged 30–79 years in 2022, underscoring a major cardiovascular risk factor. Obesity prevalence among adults aged 18 and older was estimated at 7% in 2016; however, recent trends show an increase, reaching 15% in 2022, with an annual rise of 0.6 percentage points between 2021 and 2022. The mean salt intake among adults aged 20 and older increased from 5 g/day in 2016 to 7 g/day in 2022, exceeding WHO-recommended levels and contributing to hypertension risk. Physical inactivity among adults aged 18 and older was reported at 18% in 2022, reflecting a sedentary lifestyle trend [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. In Somaliland, tobacco use was reported at 27% and khat use at 37% among adults in 2022, based on regional data, highlighting significant behavioral risk factors for NCDs [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eKey NCD progress indicators status in Somalia and EMRO region\u003c/h2\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv class=\"gridtable\"\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\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e\u003ccolgroup cols=\"5\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNO\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eindicators\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSomalia\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eEMRO Region\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eAfrican Region\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eProbability of premature mortality from NCDs (2019)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e29%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e23%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e21%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003ePercentage of total deaths due to NCDs (2019)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e63%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e37%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003ePercentage of NCD deaths occurring under 70 years (2019)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e72%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e56%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e61%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eNCD age-standardized death rate (2019)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e816 per 100 000 population\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e624 per 100 000 population\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e595 per 100 000 population\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eMortality rate attributed to household and ambient air pollution (2019)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e238 per 100 000 population\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e136\u0026nbsp;per 100 000 population\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e163 per 100 000 population\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003ePopulation with primary reliance on polluting fuels and technologies (2020)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e97% (95% in urban and 100% in rural)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e27% (urban 8% and rural = 47%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e80% (61% in urban and 94% in rural)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eCancer age-standardized death rate (2019)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e129 per 100 000 population\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e105\u0026nbsp;per 100 000 population\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e123 per 100 000 population\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eTotal cancer deaths (2019)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8583\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e484966\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e665188\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eCRD age-standardized death rate (2019)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e68 per 100 000 population\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e42 per 100 000 population\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e37 per 100 000 population\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eCVD age-standardized death rate (2019)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e315 per 100 000 population\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e329 per 100 000 population\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e255 per 100 000 population\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eDiabetes age-standardized death rate (2019)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e59 per 100 000 population\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e32 per 100 000 population\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e40 per 100 000 population\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003ePercentage of diabetes deaths occurring under 70 years (2019)\u003c/b\u003e\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\u003e55%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e56%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eNCD risk factors\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eRaised fasting blood glucose, adults aged 18+ (2014)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eOverweight, adults aged 18 + and adolescents (2022)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35% (21% male and 49% female)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e60% and 27% respectively\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e31% (24% male and 39% female)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eObesity, adults aged 18 + and adolescents (2022)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e29% and 11% respectively\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e12%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eObesity among adolescents aged 10–19 (2022)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eMean population salt intake, adults aged 25+ (2019)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7g / day\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7g / day\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7g/day\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003ePhysical inactivity among adults (18+) or adolescents (11–17 years) (2022)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18% among adults with no data among adolescents\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e40% among adults and 87% among adolescents\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e17% among adults and 85% among adolescents\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eCurrent tobacco use, adults aged 15+ (2022)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo data\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e10%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003eSource: WHO EMRO NCD data portal [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eChallenges in integrating NCD services into the primary system\u003c/h2\u003e\u003cp\u003eSomalia's history of protracted conflict and ongoing fragility has severely damaged its healthcare infrastructure, compromising access to essential health services, particularly for the long-term management of chronic conditions [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe scarcity of trained healthcare professionals, including physicians, nurses, and allied health workers with expertise in NCDs, further exacerbates these challenges, hindering the provision of adequate and specialized care for individuals living with these diseases. Somalia’s HRH index stands less than 1 skilled health workers per 1000 population, below the WHO recommended 2.3 skilled health worker per 1000 population [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Urban hospitals have more doctors and nurses than rural facilities, but specialized NCD personnel, including specialist physicians, diabetic/psychiatric nurses, community health workers, and nutritionists, are largely absent.\u003c/p\u003e\u003cp\u003eHealth facility capacity for NCD management is severely limited, as revealed by the 2023 Harmonized Health Facility Assessment (HHFA). Only 29% of facilities offer cardiovascular and diabetes services, 24% for asthma, 16% for chronic obstructive pulmonary disease, 12% for mental health, and 6% for cancer. Primary Health Units provide minimal NCD services, with only 3% offering hypertension, diabetes, or asthma management, while public hospitals offer higher coverage, such as 57% for cardiovascular disease and 54% for diabetes. Cancer services are limited, even in private specialty hospitals at 20% [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFacility readiness is inadequate, with aspirin available in 67% of facilities but fewer than 50% having calcium channel blockers, beta-blockers, or statins. Metformin is available in 62% of facilities, injectable glucose in 60%, and insulin in 47%. Diagnostic tests for diabetes are available in less than 40% of health centers and 25% of Primary Health Units [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Cancer screening and treatment are nearly absent. Advanced diagnostics, such as echography and CT, MRI and PET scanners, are lacking in major public facilities, and available equipment is often non-functional due to a lack of expertise [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Essential NCD tools, including monofilaments and spirometers, are absent, and reliance on paper records hinders data collection.\u003c/p\u003e\u003cp\u003eLaboratories lack capacity for specific NCD tests, such as urine macro albumin and cancer diagnostics, with inadequate reagent storage compromising test reliability. Advanced tests like hemoglobin electrophoresis are unavailable. Public hospitals lack dedicated NCD clinics, and diagnostic services, including BMI calculation, eye exams, and cancer screening, are limited. Palliative care, chemotherapy, and radiotherapy are absent in public facilities. First-line drugs for hypertension and diabetes are available, but second-line drugs and anticancer medications are scarce. Guidelines for diabetes and hypertension exist, but those for cancer, mental health, and palliative care are lacking. Few hospitals have formal referral protocols, and community NCD education is minimal, limiting prevention and follow-up [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFinancial constraints and the need to address competing health priorities, such as infectious diseases, maternal and child health, and emergency response, often lead to insufficient allocation of resources towards NCD prevention and control programs. This resource-limited environment makes it difficult to establish and sustain effective long-term NCD programs, necessitating the development of innovative and cost-effective solutions [\u003cspan additionalcitationids=\"CR39\" citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e–\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eThe frequent humanitarian crises that affect Somalia, including conflict-induced displacement, recurrent droughts leading to food insecurity, and other natural disasters, have a significant and multifaceted impact on the rising burden of NCDs [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Displacement can disrupt the continuity of care for individuals already diagnosed with NCDs, leading to potential complications and poorer health outcomes due to lack of access to medication, regular check-ups, and specialized services [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eHumanitarian emergencies can also exacerbate key NCD risk factors, such as poor dietary habits resulting from food shortages, increased levels of stress due to insecurity and displacement, and further reduced access to already strained healthcare services [\u003cspan additionalcitationids=\"CR45\" citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e–\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. The immediate focus on life-saving interventions during these crises may inadvertently overshadow the longer-term healthcare needs of individuals living with NCDs. Moreover, the experience of trauma and displacement can increase the risk of mental health disorders, which are increasingly recognized as important NCDs or risk factors for other NCDs [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. The cyclical nature of humanitarian crises in Somalia can create a detrimental feedback loop, where NCDs are both aggravated by the crises and, in turn, hinder recovery efforts due to increased morbidity and mortality within the affected population [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWhile the Somali Federal Ministry of Health (FMoH) has acknowledged the increasing threat of NCDs and is taking steps to address them, there may still be gaps in the comprehensiveness and effective implementation of national health policies, strategies, and specific action plans targeting NCD prevention and control [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. The Health Sector Strategic Plan 2022–2026 (HSSP III) recognizes the growing burden of NCDs and includes them as one of its key priority areas, highlighting mental health, diabetes, and hypertension as major neglected conditions [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. The revised Essential Package of Health Services (EPHS) 2020 also includes NCDs as one of its six key areas, focusing on health promotion and disease prevention, cardiovascular and pulmonary diseases, diabetes, cancer, mental health and substance use disorders, injuries, and other NCDs [\u003cspan additionalcitationids=\"CR52\" citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e–\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. The ongoing development of the first national NCD policy and strategy, with support from international organizations, signals a growing recognition of the need for a more structured and comprehensive approach to NCD governance and leadership in Somalia. This policy aims to strengthen the governance capabilities of the FMoH and create multi-sectoral steering committees at both national and sub-national levels [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSociocultural factors and stigma surrounding NCDs can also pose challenges to effective governance and individual health-seeking behaviors in Somalia. Awareness of NCD risk factors and the importance of early detection and management are limited in some communities. Traditional beliefs and practices may influence health behaviors and access to formal healthcare services for NCDs [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. Addressing these sociocultural barriers through culturally appropriate health education and community engagement strategies is crucial for improving NCD prevention and control efforts.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eEnablers and Opportunities for Strengthening NCD Governance and leadership\u003c/h2\u003e\u003cp\u003eDespite the significant challenges, Somalia possesses certain healthcare infrastructures and potential resources that can be leveraged to strengthen NCD governance and improve the health outcomes of its population [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. The strong Community health worker (CHW) programme represents a particularly valuable asset in Somalia's healthcare system, acting as a vital link between communities and the formal health system [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. These programmes have the potential to play a crucial role in NCD prevention by raising awareness about risk factors and promoting healthy lifestyles [\u003cspan additionalcitationids=\"CR56\" citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e–\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]. CHWs can also contribute to early detection through community-based screening initiatives and facilitate access to care by referring individuals with suspected NCDs to health facilities. Furthermore, CHWs can support community-level management of NCDs by providing health education, medication adherence support, and follow-up care, especially in underserved and remote areas where access to formal healthcare facilities is limited [\u003cspan additionalcitationids=\"CR59 CR60\" citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e–\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e]. Integrating NCD-focused interventions into the existing primary healthcare system, as outlined in the Essential Package of Health Services (EPHS) 2020, offers a significant opportunity to reach a broader segment of the population with essential NCD services [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. Enhancing the capacity of CHWs to address NCDs through targeted training, providing them with the necessary tools and resources, and ensuring their effective integration into the primary healthcare network could be a cost-effective and sustainable strategy to improve access to NCD care in Somalia's resource-constrained environment.\u003c/p\u003e\u003cp\u003eThe sizable Somali diaspora represents another crucial resource that can be strategically mobilized to support the health sector in Somalia, including in the critical area of NCDs. The diaspora possesses a wealth of expertise, skills, and financial resources that can be channeled towards strengthening healthcare systems and addressing specific health challenges. Initiatives such as the Migration for Development in Africa (MIDA) FINNSOM project have successfully demonstrated the potential of engaging diaspora professionals in contributing to policy development, capacity building within health institutions, and improving the delivery of essential health services, including in the area of NCDs [\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e]. Furthermore, numerous diaspora organizations are actively involved in providing direct healthcare services, donating medical supplies, and supporting health-related initiatives within Somalia. Actively fostering partnerships and developing targeted programs to effectively engage the Somali diaspora can provide much-needed technical expertise, financial support, and innovative solutions to combat the growing burden of NCDs in the country [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eLearning from the experiences of other low-resource settings and countries that share similar socio-economic and political contexts with Somalia can provide valuable insights and adaptable models for successful NCD prevention and management [\u003cspan additionalcitationids=\"CR67\" citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e–\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e]. The World Health Organization (WHO) Package of Essential Noncommunicable Disease Interventions (WHO PEN) for primary care in low-resource settings offers a prioritized set of cost-effective interventions that have been designed for implementation even in resource-poor environments [\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e]. These interventions focus on early detection, treatment, and management of major NCDs at the primary care level. Strategies such as task-shifting specific NCD care responsibilities to community health workers and leveraging the increasing accessibility of mobile health (mHealth) interventions have shown promising results in improving NCD care delivery and management in various LMICs [\u003cspan additionalcitationids=\"CR71\" citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e–\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAdapting exercise-based rehabilitation programs for NCDs to low-resource settings by training non-conventional health workers and integrating rehabilitation into community health centers has also demonstrated feasibility [\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e, \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e]. By carefully examining and adapting evidence-based interventions that have proven successful in comparable settings, Somalia can potentially accelerate its progress in addressing NCDs, saving valuable time and limited resources by building upon existing knowledge and best practices.\u003c/p\u003e\u003c/div\u003e"},{"header":"DISCUSSION AND RECOMMENDATIONS","content":"\u003cp\u003eThe findings of this desk review highlight the significant and growing burden of NCDs in Somalia, evidenced by the high prevalence of conditions like hypertension and diabetes and their substantial contribution to overall morbidity and mortality [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e]. This epidemiological shift necessitates a fundamental change in the approach to healthcare, moving beyond a primary focus on communicable diseases and maternal and child health to integrate comprehensive NCD prevention and management strategies [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e]. The complex interplay of a fragile health system, recurrent humanitarian crises, and diverse socio-demographic factors creates a particularly challenging environment for effective NCD governance and leadership [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe growing prevalence of chronic conditions among women, urban residents, older adults, and those with higher socioeconomic status underscores the need for targeted interventions that address these specific population groups. For instance, interventions in urban areas might focus on promoting healthy diets and physical activity in the face of changing lifestyles, while efforts targeting older adults need to address the increasing multimorbidity associated with aging. The higher prevalence among wealthier and more educated individuals might reflect better access to diagnosis, but it also suggests a need to understand the behavioral and environmental factors driving NCDs in these groups [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eLessons from successful NCD interventions in low-resource settings provides valuable guidance for adapting evidence-based approaches in Somalia. Specifically, Somalia should integrate NCD prevention and management into its primary healthcare system, drawing inspiration from the effective implementation of the World Health Organization’s Package of Essential Noncommunicable Disease Interventions (WHO PEN) in Nepal, Myanmar and Indonesia. In these countries, which face resource constraints and histories of political instability similar to Somalia, WHO PEN was implemented in primary health centers to address cardiovascular diseases and diabetes. By training non-specialist health workers, including community health workers (CHWs), to conduct basic screenings, deliver lifestyle counseling, and manage essential medications such as metformin and antihypertensives, Nepal, Myanmar and Indonesia enhanced access to NCD care, improving screening, diagnosis, treatment, and follow-up in underserved areas. For Somalia, where only 29% of health facilities offer cardiovascular and diabetes services, integrating WHO PEN into the Essential Package of Health Services (EPHS) 2020 could strengthen NCD management, provided investments are made in training, diagnostic tools, and reliable drug supply chains to address the country’s fragile health infrastructure and frequent humanitarian disruptions [\u003cspan additionalcitationids=\"CR78\" citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e–\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTo strengthen care delivery within Somalia’s fragmented health system, mobile health (mHealth) technologies present a transformative opportunity, as evidenced by their success in low-resource and conflict-affected settings globally. In DRC, Cambodia and the Philippines, mHealth platforms have enabled SMS reminders for diabetes medication adherence and remote patient monitoring, improving outcomes in underserved regions [\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e]. Somalia, where paper-based records impede data collection and conflict frequently disrupts connectivity, could adopt low-cost, offline-capable mHealth solutions to track patients with chronic conditions, such as hypertension, and deliver education on risk factors. Integrating NCD indicators into Somalia’s existing District Health Information System 2 (DHIS2), already used for health data recording and decision-making, could enhance monitoring of NCD prevalence, treatment outcomes, and service gaps, as demonstrated in Bangladesh, where DHIS2 integration improved data-driven decision-making for hypertension data [\u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e]. However, experiences from other conflict-affected states underscore the need for reliable technical support, and robust data protection to sustain mHealth programs [\u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e, \u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e]. Somalia must prioritize offline-compatible mHealth tools, train local staff to maintain systems, and address low community awareness and stigma around NCDs to ensure adoption.\u003c/p\u003e\u003cp\u003eCommunity engagement is another vital strategy, inspired by successful models in low- and middle-income countries, where community empowerment has addressed NCD concerns [\u003cspan additionalcitationids=\"CR85 CR86 CR87\" citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e–\u003cspan citationid=\"CR88\" class=\"CitationRef\"\u003e88\u003c/span\u003e]. Somalia can engage communities through culturally sensitive campaigns, leveraging local leaders to counter traditional beliefs that deter health-seeking behavior. The Somali diaspora, a unique asset, can amplify these efforts, as seen in the MIDA FINNSOM project, which mobilized diaspora expertise to strengthen health systems. By involving diaspora professionals in training CHWs or funding community health initiatives, Somalia can enhance NCD education and service delivery.\u003c/p\u003e\u003cp\u003eThe ongoing development of a national NCD policy and strategy is a critical step towards establishing a more robust and coordinated framework for addressing the growing NCD burden in Somalia. This policy needs to be comprehensive, multi-sectoral, and aligned with the existing Health Sector Strategic Plan and global best practices. Effective implementation of this policy, with clear targets, allocated resources, and robust monitoring and evaluation mechanisms, will be crucial for achieving meaningful progress in NCD prevention and control.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eSomalia is facing a significant and escalating crisis of non-communicable diseases that demands urgent and concerted action from all stakeholders. While the country grapples with numerous challenges, including a fragile health system, recurrent humanitarian emergencies, and limited resources, there are also notable enablers and opportunities that can be leveraged to strengthen NCD governance and leadership. This desk review underscores the critical need for a comprehensive and multi-sectoral approach to address the rising burden of NCDs in Somalia. Key strategic recommendations include strengthening the integration of NCD services into the primary healthcare system, enhancing the capacity of community health workers to address NCDs, actively engaging the Somali diaspora in NCD prevention and control efforts, learning from successful interventions in similar settings and finalizing and effectively implementing the national NCD policy and strategy. Addressing the growing epidemic of NCDs is essential for improving the health and well-being of the Somali population and for achieving the Sustainable Development Goals, particularly SDG 3. Sustained commitment, investment, and collaboration among all stakeholders are crucial to navigate this crisis and build a healthier future for Somalia.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBennett JE, Stevens GA, Mathers CD, Bonita R, Rehm J, Kruk ME et al (2018) NCD Countdown 2030: worldwide trends in non-communicable disease mortality and progress towards Sustainable Development Goal target 3.4. Lancet 392(10152):1072\u0026ndash;1088\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWHO Website Non communicable diseases [Internet]. [cited 2025 Apr 8]. 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Nutrients 15(3):791\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKrishnan A, Ekowati R, Baridalyne N, Kusumawardani N, Suhardi, Kapoor SK et al (2011) Evaluation of community-based interventions for non-communicable diseases: experiences from India and Indonesia. Health Promot Int 26(3):276\u0026ndash;289\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAkter K, Kuddus A, Jeny T, Nahar T, Shaha S, Ahmed N et al (2023) Stakeholder perceptions on scaling-up community-led interventions for prevention and control of non-communicable diseases in Bangladesh: a qualitative study. BMC Public Health 23(1):719\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":"","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":"Non-Communicable diseases, Health equity, Public health policy, NCD governance, fragile states, health system strengthening, integrated healthcare systems, Sustainable Development Goals.","lastPublishedDoi":"10.21203/rs.3.rs-7923919/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7923919/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground\u003cbr\u003e\nNon-Communicable diseases (NCDs) such as cardiovascular issues, diabetes, various cancers, and chronic respiratory diseases are becoming a significant public health issue in Somalia, a country affected by conflict and instability. Traditionally, Somalia has faced challenges from communicable diseases, but the landscape is shifting. NCDs now contribute to roughly 30% of premature mortality in the nation. This desk review explores the prevalence of these diseases, the governance challenges that exist, and the opportunities for enhancing health system responses to the increasing burden of NCDs in Somalia.\u003cbr\u003e\nMethodology\u003cbr\u003e\nThe methodology implemented a dual-modal search strategy to ensure maximal evidence capture. First, we performed a systematic sweep of the academic landscape using key platforms: PubMed, Scopus, and Google Scholar. Second, we conducted a parallel review of crucial grey literature, actively seeking policy documents and national reports from organizations like the WHO and the Somali Ministry of Health. Only material published in English within the past ten years, and specific to NCDs in Somalia, was deemed eligible. Following data extraction, the information was thematically consolidated and rigorously appraised, with each source’s quality being judged by its underlying study methodology and organizational authority.\u003cbr\u003e\nResults\u003cbr\u003e\nNCDs account for approximately 30% of premature deaths in Somalia. Hypertension (33%) and diabetes (20%) being the most prevalent. Women, urban residents, older adults, and wealthier individuals report higher prevalence. Challenges include a fragile health system, with only 29% of facilities offering cardiovascular and diabetes services, a severe shortage of skilled health workers, and limited diagnostic and treatment capacity. Recurrent humanitarian crises exacerbate NCD risk factors and disrupt care. Opportunities include leveraging community health worker programs, engaging the Somali diaspora, and adapting WHO’s Package of Essential NCD Interventions (PEN). The ongoing development of the national NCD policy signals progress.\u003cbr\u003e\nConclusion\u003cbr\u003e\nThe escalation of NCDs in Somalia demands urgent, coordinated efforts. The primary recommendations for action include: fully implementing the national NCD policy, integrating NCD treatment into primary healthcare, scaling up Community Health Worker (CHW) capabilities, and increasing the mobilization of the diaspora. Success hinges on adapting interventions locally and ensuring a multi-sectoral response is sustained to effectively improve public health and contribute to Sustainable Development Goal 3 (SDG 3) attainment.\u003cbr\u003e\n\u003c/p\u003e","manuscriptTitle":"The Silent Epidemic: Strengthening Governance and Health System Resilience against Non-Communicable Diseases in Somalia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-23 06:10:04","doi":"10.21203/rs.3.rs-7923919/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 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":56711763,"name":"Health Economics \u0026 Outcomes Research"},{"id":56711764,"name":"Health Policy"},{"id":56711765,"name":"Health Law"}],"tags":[],"updatedAt":"2025-10-23T06:10:04+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-23 06:10:04","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7923919","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7923919","identity":"rs-7923919","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}