The Unrecognized Challenge: A Value-Based Policy Approach to Combat Non-Communicable Diseases in Somalia's Health Sector

The Unrecognized Challenge: A Value-Based Policy Approach to Combat Non-Communicable Diseases in Somalia's Health Sector | 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 Research Article The Unrecognized Challenge: A Value-Based Policy Approach to Combat Non-Communicable Diseases in Somalia's Health Sector Abdirezak Abdi, Abdirezak Mawlid Abdi, Hamdi osman, Mahamed Muhumed This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7925625/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), encompassing conditions such as hypertension, diabetes, and cancers, have rapidly transitioned from a secondary concern to a significant public health threat in Somalia. This epidemiological shift necessitates urgent examination of the healthcare system’s fundamental capacity to address chronic conditions. NCDs currently account for an estimated 25% to 30% of all fatalities, highlighting the severe disconnect between the traditional acute-care focus of the Somali health system and the requirements of long-term chronic disease management. This report analyzes the systemic barriers inhibiting effective NCD control and proposes a Value-Based Care (VBC) centered policy roadmap for sustainable health system transformation. Methodology: A systematic policy synthesis was conducted, aligning with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) framework. The analysis included a comprehensive review of peer-reviewed literature indexed in databases such as PubMed, Scopus, and Google Scholar, alongside grey literature from the World Health Organization (WHO), the Global Burden of Disease (GBD) project, and official Somali Ministry of Health reports published within the last decade. Data were thematically synthesized using the WHO Health Systems Building Blocks as the a priori analytical framework, and policy recommendations were graded using established criteria to assess the certainty of evidence. Results Key findings confirm a severe NCD burden (e.g., hypertension affecting approximately 33% and diabetes affecting 20% of the adult population). Systemic challenges are categorized under four pillars: ( 1 ) Governance, characterized by service fragmentation and a weak regulatory environment; ( 2 ) Financing, dominated by a fee-for-service model and resulting in high catastrophic health expenditure (CHE) for NCD households; ( 3 ) Workforce, facing an acute scarcity (0.11 clinicians per 1,000 population) and training misalignment; and ( 4 ) Information, plagued by low reporting rates in the DHIS2 system (around 50%). A crucial finding is the unique role of Khat chewing as a major behavioral and policy target driving hypertension and complicating mental health integration. Conclusion Somalia faces a multi-faceted crisis requiring a comprehensive, multi-sectoral response. The adoption of a phased VBC roadmap, focusing on financial model revision, task-shifting integration (WHO PEN/HEARTS), and rigorous, adapted outcome measurement (PROMs/ObSROMs), is essential. Strategic policy alignment, including finalizing the National NCD Policy and strengthening federal-state accountability, is necessary to transition the health system from a reactive model to one capable of achieving global targets for NCD control (SDG 3.4). Health Economics & Outcomes Research Health Policy Health Law Non-Communicable Diseases health system challenges Somalia Value-Based Care healthcare policy Sustainable Development Goals Khat Fragile States 1. Introduction: NCDs in Fragile State Settings 1.1. The Global Imperative: NCDs, Sustainable Development, and Fragile Contexts 1.1.1. NCDs and the Global Burden of Disease (GBD) Globally, the epidemiological transition continues to shift the predominant causes of morbidity and mortality toward chronic, non-communicable conditions. Projections indicate that NCDs will be responsible for approximately 70% of all deaths worldwide by 2030. For countries like Somalia, which have historically focused resources and policy on infectious and maternal/child health issues, this transition represents a fundamental threat to public health stability. To accurately quantify the impact of NCDs, analysis must move beyond simple mortality statistics to comprehensive metrics of health loss. The Disability-Adjusted Life Year (DALY) calculation, which represents the sum of Years of Life Lost (YLLs) due to premature mortality and Years Lived with Disability (YLDs), serves as a critical indicator. In a context like Somalia, where NCDs contribute significantly to long-term impairment (such as diabetes-related complications or hypertension-related stroke), the DALY burden underscores the immense strain placed on productive human capital and family resources, demonstrating that the burden extends far beyond immediate fatality counts. 1.1.2. The Double Burden of Disease in Fragile and Conflict-Affected States (FCAS) Somalia, classified as a fragile and conflict-affected state, manages the complex challenge of a "double burden" of disease. Historically, the nation has grappled with a high incidence of communicable, maternal, perinatal, and nutritional conditions, which accounted for an estimated 63.8% of deaths in 2021. This acute burden demands emergency preparedness and intervention-focused medical responses. However, recent trends confirm a rapid increase in chronic disease prevalence. NCDs now represent a substantial cause of death, contributing between 25.1% and 30% of all fatalities. This rapid shift presents a significant challenge: the existing health system infrastructure and financial architecture are optimized for acute, infectious disease responses, not the continuous, infrastructure-heavy care, long-term monitoring, and preventative strategies required for NCD management. The very fragility that characterizes the system, often created by prolonged conflict and instability, exacerbates NCD risk factors (e.g., stress, poor diet, limited access to stable health services) while simultaneously inhibiting the implementation of the long-term system investments necessary for chronic care management. This creates a critical paradox wherein the operational environment that generates NCD risks actively prevents sustainable systemic solutions, necessitating a resilience-centric approach to policy design. 1.1.3. NCD Management as a Precondition for SDG Achievement Effective NCD management is not merely a sectoral health goal; it is foundational to achieving the broader Sustainable Development Goals (SDGs). Specifically, NCD control is mandated under SDG 3.4 (to reduce premature mortality from NCDs by one-third by 2030). Failure to achieve this target directly compromises progress toward poverty eradication (SDG 1.1.1). Chronic illnesses impose recurrent, often catastrophic, health expenditures on affected households. The financial shock associated with NCD treatment, prolonged hospitalizations, and lost income drives families into extreme poverty. Therefore, strengthening NCD care, especially through preventative strategies and chronic management at the primary healthcare (PHC) level, becomes a crucial mechanism for financial protection and poverty alleviation. The policy roadmap proposed herein views NCD management as an essential component of national development and long-term stability, not just a clinical endeavor. 1.2. Geo-Political and Health System Context of Somalia 1.2.1. Historical Background and Healthcare System Fragmentation Somalia’s health system has been severely weakened and fragmented by decades of civil conflict and political instability. The resulting environment is characterized by diverse, often uncoordinated, service providers, including private actors, non-governmental organizations (NGOs), and governmental institutions. Current government efforts are guided by the National Health Sector Strategic Plan (HSSP III, 2022–2026), which provides the overarching policy direction for the health sector. However, the successful implementation of this plan, particularly concerning complex challenges like NCDs, depends heavily on overcoming deep-seated issues of fragmentation and resource scarcity that have plagued the sector for decades. 1.2.2. Defining the Crisis The scale of the crisis is quantifiable through key indicators. Somalia’s Universal Health Coverage (UHC) index remains critically low, estimated at only 25%. This implies that three-quarters of the population lacks access to essential health services without facing potentially crippling financial hardship. Compounding this, the health workforce density stands at an alarmingly low 0.11 clinicians per 1,000 population. The rising NCD burden, therefore, should be defined not only as a clinical or public health challenge but as a major developmental and security risk. An unhealthy population, burdened by chronic disease and financial toxicity, compromises national resilience and socio-economic progress. Given the country’s inherent institutional weakness, the NCD threat must be addressed through strategic, evidence-based interventions that prioritize system resilience. 1.3. Rationale and Structure of the Manuscript 1.3.1. Policy Gap Analysis A critical policy gap exists in Somalia regarding comprehensive NCD management. Compared to neighboring countries like Kenya and Ethiopia, which have made significant advancements in developing robust NCD management frameworks, Somalia lags significantly. These regional peers have successfully implemented national policies aimed at integrating NCD care into primary healthcare and scaling community health initiatives. Somalia’s fragmentation, coupled with a reactive budgeting approach, inhibits the development of a cohesive national strategy, resulting in effective interventions often remaining isolated and failing to reach the rural populations most in need. 1.3.2. Objectives and Thesis This article aims to explore the challenges posed by the rising NCD epidemic in Somalia through a detailed analysis of structural barriers, organized around the WHO Health Systems Building Blocks. The ultimate goal is to deconstruct these systemic challenges and propose a comprehensive, Value-Based Care (VBC) centered policy roadmap. This roadmap focuses on integrating NCD prevention, diagnosis, and long-term chronic management effectively into the Primary Healthcare (PHC) framework, thereby supporting sustainable health system transformation in a fragile setting. 2. Methodology and Analytical Framework 2.1. Study Design: A Mixed-Methods Policy Synthesis Approach The study adopted a policy synthesis approach, utilizing a systematic review methodology to analyze the heterogeneous data available concerning NCDs and health systems in Somalia. Given the scarcity of primary intervention studies in conflict-affected settings, this approach allowed for the comprehensive assessment and thematic integration of epidemiological data, qualitative assessments of systemic barriers, and policy documentation. 2.1.1. Rationale for Systematic Literature Review The systematic literature review focused on studies published in English over the last decade that specifically address NCD prevalence, risk factors, health system challenges, and policy interventions within the Somali context. This timeframe captures the critical period during which Somalia experienced its rapid epidemiological transition toward chronic conditions, providing the most relevant data for policy formulation. 2.1.2. Search Strategy and Databases The primary search strategy employed a combination of key terms related to the condition ("Non-Communicable Diseases," "Hypertension," "Diabetes"), the geographic location ("Somalia," "Somaliland," "Horn of Africa"), and systemic barriers ("health system challenges," "fee-for-service," "primary healthcare integration," "fragile states"). Databases utilized included PubMed, Scopus, and Google Scholar. To ensure the inclusion of critical governmental and organizational perspectives often unavailable in peer-reviewed literature, the search was supplemented by targeted searches of grey literature, including reports from the WHO, the Global Fund, and the Somali Ministry of Health. 2.1.3. Selection Criteria and Screening Studies were included if they provided empirical data on NCD prevalence, addressed health service delivery barriers specific to NCDs, or analyzed policy and financing mechanisms within the Somali or closely related Fragile State contexts. Exclusion criteria included studies not published in English, reports older than 10 years, or studies where the findings could not be specifically contextualized to the Somali health system. Thematic relevance was prioritized during screening. 2.2. Data Extraction, Synthesis, and Quality Appraisal 2.2.1. PRISMA Alignment and Flow Diagram Although the study is a policy review rather than a meta-analysis of intervention efficacy, the methodology was aligned with the PRISMA 2020 (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. This commitment to transparency requires a detailed documentation of the study selection process, typically presented through a PRISMA flow diagram (Appendix A). This ensures clarity in reporting why studies were included or excluded, lending robust validation to the synthesized policy conclusions. 2.2.2. Quality Appraisal Instruments Rigor in synthesizing evidence requires a formal appraisal of the methodological quality and certainty of the included documentation. For prevalence data derived primarily from cross-sectional or observational studies, the Newcastle-Ottawa Scale (NOS) was applied to assess quality metrics such as selection, comparability, and outcome reporting. To assess the strength of the resulting policy recommendations, the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) system was utilized. GRADE provides a structured approach for evaluating the overall certainty of evidence and determining the strength of subsequent policy prescriptions, moving the manuscript beyond a simple narrative review to a credible foundation for national policy development. 2.2.3. Thematic Synthesis Data extraction focused on identifying key barriers and opportunities within the established framework of the WHO Health Systems Building Blocks . This framework ensures a comprehensive analysis covering: Service Delivery, Health Workforce, Health Information Systems, Medical Products and Technologies, Health Financing, and Leadership/Governance. Utilizing this universally recognized a priori structure allows for the systematic comparison of Somalia's NCD challenges across critical system components and facilitates the development of targeted, integrated policy solutions. The analysis revealed that systemic instability, particularly in governance and financing, creates quality disparities and bottlenecks for implementation. Specifically, the fragmented, private-dominant nature of service delivery operating under weak regulation creates inherent inconsistencies in the quality of NCD care. This lack of standardization is fundamentally antithetical to the continuity and predictability required for Value-Based Care (VBC). Therefore, system-wide governance strengthening and standardization must run parallel to, or precede, VBC implementation to ensure that quality is uniformly delivered across the provider network. 3. Epidemiological Transition: Quantifying the NCD Burden 3.1. Current Prevalence and Disease Profile The burden of NCDs in Somalia has reached a critical threshold, demanding resources and systemic attention comparable to communicable diseases. The current data reveals alarmingly high prevalence rates for major NCDs, often linked to lifestyle changes and the effects of chronic instability. 3.1.1. Hypertension and Diabetes Hypertension and Type 2 Diabetes Mellitus are the most prevalent NCDs and represent the immediate threat to the adult population. According to the Somali Health and Demographic Survey (2020), hypertension affects a staggering 33% of the adult population. The prevalence of diabetes stands at approximately 20%. These conditions are silent epidemics that often lead to severe complications, including cardiovascular diseases, stroke, and kidney failure, placing predictable yet overwhelming demand on tertiary care facilities. The high prevalence underscores an urgent need for widespread population screening and the integration of chronic disease management into every level of care. 3.1.2. Burden Quantified: Mortality and DALYs While Somalia historically reported that communicable, maternal, perinatal, and nutritional conditions accounted for 63.8% of deaths, the share attributable to NCDs has risen significantly, estimated at 25.1% in 2021. Other estimates place the NCD mortality share closer to 30% of all fatalities. This rapid shift demonstrates an incomplete, yet highly damaging, epidemiological transition. The significance of this burden is best understood through the calculation of Disability-Adjusted Life Years (DALYs). DALYs capture the years of healthy life lost due to premature death and disability. For Somalia, the rising NCD DALY rates signify an erosion of human capital—a loss of productive life years that hampers economic and social recovery. Analyzing DALYs, rather than simple mortality, illustrates that NCDs are chronic drivers of disability, demanding long-term care investments that the existing acute-focused system is structurally unprepared to provide. 3.1.3. Other Key NCDs Beyond diabetes and hypertension, Somalia faces a rising incidence of other NCDs, including various cancers, cardiovascular diseases (CVD), and chronic respiratory diseases. While data collection remains fragmented, these conditions contribute substantially to the overall DALY burden. Targeted screening and prevention programs, particularly for common cancers and chronic lung conditions, must be factored into the national NCD policy to manage the full scope of the disease burden. Table 1: Proposed NCD Burden Profile in Somalia (Estimated) This table presents an estimated profile of the burden of non-communicable diseases (NCDs) in Somalia, detailing prevalence rates, attributable mortality shares, DALY rate contributions relative to the Africa region average, and primary behavioral risk factors associated with each condition. NCD Indicator Prevalence (Adult Population) Attributable Mortality Share (2021 Est.) DALY Rate Contribution (Relative to Africa Region Average) Primary Behavioral Risk Factors Hypertension ~33% High (CVD) High Khat use, high salt diet, urbanization Diabetes Mellitus (Type 2) ~20% Moderate High Unhealthy diet, physical inactivity All NCDs (Total) N/A ~25.1% - 30% Critically Significant Tobacco, Khat, Diet, Insufficient physical activity Understanding the burden of non-communicable diseases in Somalia is crucial for effective health planning. Table 1 outlines the estimated NCD burden profile, including prevalence, mortality, and key behavioral risk factors." 3.2. Socio-Ecological and Behavioral Risk Factors (The Somali Context) The growing NCD burden is driven by behavioral and environmental factors unique to the Somali context, requiring specialized and culturally sensitive policy responses. 3.2.1. The Unique Role of Khat Chewing (A Major Policy Target) Khat ( Catha edulis ) chewing is a pervasive behavioral risk factor that demands specific policy attention due to its widespread cultural and economic roots. News reports and field observations indicate that up to 90% of adult males and 58% overall prevalence in affected populations regularly chew the stimulant. The health consequences are significant and directly linked to core NCDs. Khat use is strongly correlated with hypertension; a study in Hargeisa found that 53.5% of khat chewers reported Grade 1 hypertension, and 36.4% reported prehypertension. Chemically similar to amphetamine, cathinone and cathine, the active compounds in Khat, place significant strain on the cardiovascular system. Furthermore, excessive Khat use creates critical intersection points between NCDs and mental health, leading to severe mental disabilities, including anxiety, depression, and psychosis. Patients struggling with mental health issues are often non-adherent to NCD treatment regimens, creating a vicious cycle of poor outcomes. Effective NCD policy must therefore address Khat not just as a health behavior but as a complex social determinant of health. Its pervasive use drives hypertension and compromises mental health, further straining the already weak capacity to manage chronic diseases. This necessitates a multi-sectoral approach involving health, commerce (taxation/regulation), and agriculture ministries to integrate cessation and mental health support directly into NCD primary care protocols. 3.2.2. Urbanization, Diet, and Physical Activity Rapid urbanization across Somalia has initiated classic epidemiological shifts observed worldwide. Urban living often involves changes in dietary patterns, leading to increased consumption of processed foods high in sugar, salt, and unhealthy fats. Simultaneously, urbanization often reduces occupational and leisure-time physical activity. These changes align with the recognized global risk factors for NCDs, including raised blood pressure, raised blood glucose, and overweight/obesity. 3.2.3. Environmental and Humanitarian Context Ongoing instability, recurring conflict, and vulnerability to climate shocks (e.g., drought, flooding) exacerbate NCD risk factors. Climate-induced displacement and chronic humanitarian crises lead to food insecurity, often resulting in poor nutritional status, stress, and extremely limited access to stable, continuous healthcare services required for chronic conditions. Policy must embed conflict-sensitive principles to ensure that NCD adaptation measures do not worsen social or political tensions and are resilient against recurrent crises. 4. Pillar 1: Fragmentation and Governance Failures 4.1. Fragmentation of Service Delivery 4.1.1. Private Sector Dominance and Regulatory Vacuum The Somali health system is overwhelmingly dependent on the private sector, which delivers over 80% of healthcare services. While the private sector provides essential coverage in a resource-scarce environment, this dominance is problematic when coupled with a nascent regulatory framework. Institutions such as the National Health Professionals Council (NHPC) are still developing capacity and face persistent resource constraints, undermining their ability to enforce standards effectively. This lack of comprehensive regulatory oversight leads to inconsistent standards of NCD care across facilities, hindering standardized protocol implementation. The fragmentation means hospitals, clinics, and diagnostic centers often operate in isolation, prioritizing competition over collaboration, which severely complicates efforts to implement system-wide improvements like VBC models. This structural disunity prevents providers from leveraging collective bargaining power for essential resources, such as pharmaceuticals, or advocating for meaningful policy reforms. 4.1.2. The Failure of Referral Systems The absence of functional, standardized referral pathways poses a major operational barrier to providing continuous NCD care. For chronic conditions that require long-term follow-up and specialized intervention only when necessary, ineffective referral systems are detrimental. Many individuals diagnosed with NCDs do not receive the necessary follow-up care or timely specialist consultation, which significantly increases the likelihood of health deterioration and preventable complications. This dysfunction forces patients into a cycle of crisis management, where treatable chronic conditions escalate rapidly into acute emergencies, often requiring expensive hospitalization in tertiary centers rather than manageable care at the primary level. The resulting congestion and expenditure drain resources from the entire system. 4.1.3. Institutional Barriers to Scaling Even where promising pilot programs for NCD management demonstrate efficacy—for example, community health initiatives in urban centers—they frequently remain isolated successes. There is a critical lack of national frameworks and coordinated efforts necessary to replicate or fund these successful initiatives on a broader scale. This institutional deficit means effective interventions fail to reach rural populations where the need for NCD education and management is equally pressing. Addressing this requires formalized coordination and clear mechanisms for disseminating successful practices across the Federal Member States, overcoming fragmented regional implementation. 4.2. Challenges in Health Governance and Policy 4.2.1. Resource Constraints and Regulatory Oversight Robust governance is non-negotiable for system-level reform. Regulatory discussions concerning the NHPC highlight persistent resource constraints that limit its efficacy in overseeing and professionalizing the health workforce. Without sustainable funding and political empowerment, the NHPC cannot effectively enforce standards for NCD practitioners or mandate participation in quality improvement and data reporting efforts, leaving the majority of the fragmented private market unchecked. 4.2.2. Policy Development Gaps The overarching National Health Sector Strategic Plan (HSSP III) provides direction, but operational gaps remain. A critical necessity is the finalization and robust implementation of a cohesive national NCD policy. Furthermore, the lack of standardized Standard Operating Procedures (SOPs) for key logistical areas, such as the handling, distribution, quantification, and forecasting of NCD medicines and technologies, undermines the reliability of chronic care provision. Without these standardized protocols, the quality and cost-effectiveness of NCD treatment cannot be assured, making continuous care impossible. 4.2.3. Federal-State Accountability Frameworks Somalia’s federal structure introduces complexity regarding policy implementation. Ensuring uniform and equitable NCD policy implementation across all Federal Member States requires strong federal-state accountability frameworks. Policy success depends on training policymakers and health administrators to understand NCD management complexities and the principles of VBC , ensuring that resource allocation and regulatory enforcement are harmonized across disparate regions. 5. Pillar 2: Financing Deficits and Economic Catastrophe The structure of health financing in Somalia poses the most significant systemic barrier to NCD management, driving economic hardship and inefficiency. 5.1. Analysis of Current Health Expenditure and Out-of-Pocket Payments 5.1.1. Insufficient Public Health Investment The current health budget allocation reflects a reactive approach to public health crises, rather than a proactive investment in prevention. Reports indicate that less than 10% of health expenditures focus on preventive services. This limited investment starves public health education, community screening programs, and other essential activities required to manage NCD risk factors effectively. This reactive budgeting approach fosters a continuous cycle of crisis management, ensuring that resources are repeatedly allocated to expensive acute interventions instead of sustainable prevention strategies. 5.1.2. Out-of-Pocket Expenditure (OOP) and Financial Toxicity In the absence of a robust national health insurance or risk-pooling mechanism, the Somali health system relies heavily on Out-of-Pocket (OOP) payments. This reliance is the primary driver of medical impoverishment. In Sub-Saharan Africa, where financing systems struggle with prepayment contributions, the incidence of catastrophic health expenditure (CHE) is high. Crucially, the evidence shows that NCDs are a major driver of these costs; about a quarter of households affected by a noncommunicable disease incurred CHE, typically defined as health expenditure exceeding 10% of total household expenditure. This figure is substantially higher than for the general population. The components of this financial toxicity are complex, encompassing not only the direct costs of treatment, but also non-medical expenditure (e.g., travel to distant clinics for follow-up) and the pervasive issue of lost income due to prolonged illness or hospitalization. Even in instances where specific disease treatments (like for HIV/AIDS or TB) are exempted from OOP payments, households still incur CHE due to these indirect costs. This underscores that addressing the financial burden of NCDs requires systemic reform that goes beyond simple exemptions for specific drugs. 5.1.3. The Economic Burden of NCDs At the macro-level, the economic impact of NCDs is substantial, straining the fragile economy. Reports highlight that NCDs could cost the Somali economy billions each year. This macro-level financial drain results from the cumulative cost of increased hospital admissions, prolonged treatment durations, and the need for expensive specialized care, all of which divert limited resources from other critical developmental areas. The resulting lost productivity due to premature mortality and morbidity further erodes the nation's human capital, contributing to a cycle of poverty and hampering national development goals. 5.2. The Case for Shifting to Value-Based Care (VBC) The evidence of FFS failure and catastrophic health expenditure necessitates a paradigm shift in health financing. Value-Based Care (VBC) presents a foundational opportunity for systemic reform. 5.2.1. Deconstruction of Fee-for-Service (FFS) Failures The Fee-for-Service (FFS) model, currently prevalent in Somalia, directly contributes to poor NCD outcomes. By incentivizing the quantity of services (procedures, visits) over the quality of care and patient outcomes, FFS discourages essential preventive measures, early detection, and continuous chronic care management. This model ensures high cost without guaranteeing improvement in long-term patient health, particularly for conditions like hypertension and diabetes that require sustained adherence and lifestyle management. 5.2.2. Definition and Application of VBC in LMICs Value-Based Care (VBC) is a healthcare delivery model that shifts focus from service volume to patient outcomes, quality of care, and cost optimization. Under VBC, providers are incentivized to keep populations healthy and manage chronic diseases effectively, aligning the financial interests of providers with the long-term health interests of patients. Importantly, VBC is not restricted to high-income settings. Evidence from other low- and middle-income countries (LMICs) confirms its feasibility, particularly when implemented incrementally. Case studies in Africa have shown that a cohort-based approach to VBC, focusing on defined outcome metrics at predictable costs per enrolled person, can successfully initiate health system restructuring from an output-driven model to a value-based financing model. For example, pilot programs in Ghana testing VBC interventions for hypertension demonstrated improved clinical outcomes and patient satisfaction. 5.2.3. Financial Protection via VBC The analysis suggests that VBC serves as the most immediate domestic strategy for financial risk management in Somalia. Since NCDs cause recurrent, cumulative financial shocks (CHE) , shifting to outcome-based reimbursement provides a structure to mitigate financial risk and reduce health-related poverty, even before a full national health insurance scheme is feasible. By prioritizing preventative care and successful long-term chronic management, VBC reduces the frequency and severity of costly acute complications, thereby acting as an essential mechanism for financial protection against catastrophic health expenditure. 6. Pillar 3: Workforce Capacity and Integrated Service Delivery The inability to effectively address NCDs is critically dependent on the scarcity and preparedness of the health workforce, which demands innovative delivery models. 6.1. The Critical Human Resource Crisis 6.1.1. Quantifying Workforce Scarcity Somalia faces an acute human resource crisis, with a critical health workforce density of only 0.11 clinicians per 1,000 population. This density is far below the minimum recommended global threshold and is particularly problematic in rural districts, where basic primary health coverage remains the most urgent barrier to UHC. This extreme scarcity threatens to undermine any policy expansion, including the establishment of new physical infrastructure. 6.1.2. Training Deficiencies Current medical training programs exacerbate the crisis by clinging to an outdated curriculum emphasizing acute care and trauma management. This neglect of essential components of chronic disease management and prevention means the workforce is ill-prepared to address the long-term, complex nature of NCDs. Surveys of healthcare professionals reveal that many feel inadequately trained to manage chronic conditions, highlighting a significant gap between the reality of the disease burden and professional competence. 6.1.3. The Specialist Gap The lack of specialized NCD practitioners (e.g., cardiologists, endocrinologists) places an unsustainable burden on general practitioners and forces reliance on expensive, foreign-trained staff or complex referral chains that often fail. This specialist gap underscores the need for alternative, non-physician-led models of care delivery capable of managing routine NCD treatment and prevention. 6.2. Strategic Task-Shifting and PHC Integration 6.2.1. Task-Shifting as an Innovative Solution To maximize the utilization of the scarce human capital, task shifting —defined by the WHO as the reallocation of tasks from highly experienced professionals (e.g., physicians) to those with more limited training (e.g., nurses, CHWs)—is essential. Task shifting allows the existing health workforce to be utilized more efficiently, making it a powerful tool for service expansion in fragile contexts. Studies in LMICs suggest that task shifting can improve nurse satisfaction and retention, which is critical given the unprecedented migration of trained professionals to higher-income countries. Therefore, the formalization of task sharing roles for NCD management offers dual benefits: expanding care capacity and enhancing workforce stability. 6.2.2. WHO PEN and HEARTS Adaptation The adoption and adaptation of globally validated, simplified protocols are central to integrating NCD care into PHC. The WHO Package of Essential Non-Communicable Disease Interventions (PEN) provides a crucial framework for diagnosis and management in low-resource settings. Building upon this, the WHO HEARTS Technical Package offers six practical modules and an implementation guide focused on strengthening cardiovascular disease (CVD) management, including standardized protocols for hypertension and diabetes detection and treatment. These models must be adapted and implemented through cascade training systems, focusing on transferring NCD management skills to nurses and community health workers (CHWs) at the PHC level. This decentralized approach is the most realistic path to achieving wide-scale coverage in a country with low specialist density. 6.2.3. Empowering Community Health Workers (CHWs) Community Health Worker (CHW) programs are pivotal for closing the rural access gap and enhancing health literacy. Policy must prioritize the expansion of CHW programs, with specific emphasis on female CHWs and deployment incentives for rural districts. CHWs, utilizing harmonized training manuals, are uniquely positioned to bridge the gap between clinical care and community practice. Their roles must be formalized to include NCD prevention education, healthy lifestyle counseling (using models like the 5As brief intervention), promoting medication adherence, and facilitating early diagnosis. Furthermore, integrating these roles under a Value-Based Care framework, which rewards improved patient outcomes (e.g., good blood pressure control achieved at the community level), can offer dual benefits: improved NCD control and increased stability and retention of the scarce health workforce by rewarding performance. 7. Pillar 4: Data, Monitoring, and Value-Based Metrics The successful transition to VBC and evidence-based NCD policy is fundamentally dependent on robust data collection, yet the current health information systems present a major policy bottleneck. 7.1. Assessment of Health Management Information Systems (HMIS) 7.1.1. DHIS2 Status and Limitations The national Health Management Information System (HMIS) in Somalia is based on the District Health Information Software 2 (DHIS2), which serves as the national data backbone for areas like disease surveillance and immunization. However, the DHIS2 system is nascent and plagued by severe data quality and accessibility challenges. Reporting rates are critically low, hovering around 50% of health facilities, with some regions failing to submit reports for months at a time due to infrastructure, communication, and human resource constraints. Furthermore, a health system assessment revealed that over 60% of facilities lack a reliable system for collecting data. This deficiency compromises the government's ability to track health outcomes reliably. 7.1.2. Impact on Evidence-Based Policy Fragmented and unreliable data severely impede effective decision-making. Without robust data, it is nearly impossible to track NCD outcomes (e.g., patient adherence, complication rates), identify local epidemiological trends, or implement evidence-based policies that respond to regional needs. This data inadequacy is not merely an operational challenge; it functions as a policy bottleneck for VBC implementation. VBC payment models are inherently data-dependent, rewarding performance based on measured outcomes. If the underlying HMIS cannot reliably capture these metrics, VBC cannot be institutionalized effectively, leading to paralysis in policy reform. 7.2. Framework for Value-Based Outcome Measurement To overcome the data bottleneck, a phased and adaptive strategy for measuring value is required, starting with non-digital solutions where necessary. 7.2.1. Defining NCD Value The shift requires moving away from tracking simple output measures (number of clinic visits) to defining and measuring clinical outcomes that truly matter, such as \text{HbA}_{1\text{c}} control for diabetes, consistent blood pressure control for hypertension, and patient experience/satisfaction. These metrics are the foundation upon which VBC reimbursement models are built. 7.2.2. Adapting Patient-Reported Outcome Measures (PROMs) for Somalia In low-literacy settings like Somalia, standard patient-reported outcome measures (PROMs) may not be fully appropriate due to the high rate of patients (over 70% of diabetes patients in urban areas) lacking adequate education on managing their condition. Cultural barriers and low literacy require innovative approaches. The strategic use of Observer-Reported Outcome Measures (ObSROMs) , where a trained healthcare provider (like a nurse or CHW) assesses the patient's functional status and adherence, can compensate for low literacy levels. Concurrently, culturally adapted and translated PROMs should be developed to capture the patient's viewpoint, particularly on quality of life and treatment satisfaction, leveraging the local knowledge of CHWs to ensure relevance and validity. 7.2.3. Incremental Implementation To avoid overwhelming the fragile DHIS2 system, VBC implementation should be incremental. Pilot programs should start with a small cohort of established PHC centers, focusing on collecting standardized data for simplified metrics: adherence rates, complication frequency (e.g., incidence of stroke or foot ulcers), and clinical control targets. This cohort-based approach allows for iterative learning, refinement of data collection tools (including paper-based standardized registers), and gradual capacity building before full-scale digital integration is attempted. Table 2: Key Structural and Data Barriers to NCD Management and VBC This table identifies critical structural and data-related barriers affecting the management of non-communicable diseases (NCDs) and the feasibility of value-based care (VBC). It includes metrics and statistics that illustrate the impact of these barriers on NCD care. Barrier Domain Metric/Statistic Impact on NCD Care/VBC Feasibility Source Health Workforce Density 0.11 Clinicians per 1000 population Limits specialist supervision, necessitates large-scale task shifting. Service Fragmentation >80% Private Sector Delivery Inconsistent quality, hinders standardization of VBC protocols. Data System Reliability ~50% DHIS2 facility reporting rate; >60% facilities lack reliable data. Impedes tracking of outcomes necessary for VBC payment models. Prevention Funding 70% of diabetes patients lack adequate education Poor self-management, limits utility of standard PROMs. To understand the challenges faced in managing Non-Communicable diseases, it is essential to identify key barriers. Table 2 highlights the structural and data-related barriers that impact NCD management and the implementation of value-based care." 8. Synthesis and Policy Roadmap for Health System Transformation 8.1. Comparative Analysis: Lessons from Regional NCD Strategies Successful NCD strategies in neighboring states provide essential evidence for Somalia's roadmap. Both Kenya and Ethiopia have demonstrated significant progress by integrating NCD management into their Primary Health Care systems. These countries prioritized the development of comprehensive national NCD management frameworks, invested public resources into prevention, and scaled up community health initiatives. The primary lesson transferable to Somalia is the necessity of strong, coordinated policy that mandates integration. Where Somalia’s successful urban pilot programs remain isolated due to fragmentation, Kenya and Ethiopia established national mechanisms to replicate and fund these initiatives across different regions. This demonstrates that political will and institutional coordination are preconditions for scaling NCD management systems beyond localized projects. 8.2. Strategic Policy Roadmap: Aligning NCD Control with HSSP III Achieving resilient NCD management requires a phased, long-term strategic roadmap aligned with the existing National Health Sector Strategic Plan (HSSP III 2022-2026). 8.2.1. Phase I (1–2 Years): Foundation and Pilots The immediate priority must be establishing the foundational policy and operational requirements. This involves finalizing the National NCD Policy and integrating it officially into the HSSP III framework. Crucially, the Ministry of Health must standardize SOPs for NCD medicine management, quantification, and supply chain. Simultaneously, VBC pilot programs should be launched in select, regulated PHC centers, focusing on high-prevalence conditions (Hypertension/Diabetes) and utilizing adapted outcome measures (ObSROMs, clinical control targets). 8.2.2. Phase II (3–5 Years): Scaling and Integration Once pilots demonstrate success, the focus shifts to broad system scaling. This includes the formal adoption and cascade training of the WHO HEARTS/PEN models to integrate NCD chronic care management into PHC across multiple regions. NCD monitoring and VBC performance metrics must be digitally integrated into the DHIS2 system as its functionality improves. Institutional capacity strengthening must establish transparent federal-state accountability frameworks with defined NCD outcome targets. 8.2.3. Phase III (Long-Term): Financial Resilience The long-term goal is financial sustainability and protection. This phase involves expanding the UHC index beyond the current 25% , developing sustainable public risk-pooling mechanisms, and institutionalizing VBC as the default reimbursement model. Success in this phase will significantly reduce catastrophic out-of-pocket expenditures for NCD patients. 8.3. Detailed Implementation Strategies 8.3.1. Financial Model Revision The transition from FFS to outcome-based contracts should begin with piloting bundled payments for chronic care packages (e.g., a defined annual budget covering routine monitoring, medication, and counseling for diabetes management). Providers would be rewarded for achieving target outcomes (e.g., keeping \text{HbA}_{1\text{c}} or blood pressure below defined thresholds) rather than the volume of services delivered. This provides a direct financial incentive for preventative measures and adherence support. 8.3.2. Infrastructure Investment for Continuity Targeted capital investment is required to equip rural PHC centers specifically for NCD management. This includes securing essential NCD medication supplies (aligned with new SOPs) and technology for data collection (e.g., reliable blood pressure monitors, glucose meters) and patient management systems. Furthermore, investment must focus on establishing reliable, two-way standardized referral pathways to ensure continuity of care, preventing PHC patients from defaulting to expensive emergency care. 8.3.3. Policy for Community Empowerment A robust strategy for enhancing health literacy is paramount. This requires the implementation of culturally sensitive, targeted educational campaigns delivered through expanded CHW networks. Crucially, specific policy interventions must address the complex behavioral risk factors, including coordinated policy and economic action (e.g., taxation, regulation) targeting Khat use to mitigate its documented association with hypertension and mental health decline. Table 3: Phased Roadmap for NCD Integration into Primary Healthcare (PHC) This table outlines a strategic framework for integrating non-communicable diseases (NCDs) into primary healthcare systems. It details key interventions across four pillars: Financing Models, Workforce Capacity, Policy & Governance, and Data & Monitoring, with specific short-term (1-2 years) and long-term (3-5 years) goals for each intervention. Pillar of Transformation Intervention Type Short-Term Goals (1-2 Years) Long-Term Goals (3-5 Years) Financing Models VBC Transition/OOP Reduction Implement VBC pilot programs focused on BP/Glucose control in PHC centers; Finalize National NCD SOPs/drug quantification. Develop public risk-pooling mechanisms; Reduce reliance on catastrophic OOP expenditure. Workforce Capacity Task-Shifting/Training Pilot WHO HEARTS/PEN cascade training for CHWs and nurses. Conduct immediate needs assessment for chronic care specialists. Integrate chronic care management and preventive education into national medical curricula ; Achieve WHO minimum specialist density in PHC catchment areas. Policy & Governance Regulatory Frameworks Finalize and adopt National NCD Policy; Establish transparent federal-state NCD target accountability. Fully fund and empower the NHPC to regulate private NCD services; Integrate NCD planning into HSSP framework reviews. Data & Monitoring HMIS/VBC Metrics Adapt PROMs/ObSROMs for low-literacy context; Improve DHIS2 reporting rates to above 70% in pilot regions. Fully integrate NCD surveillance and VBC performance tracking into a resilient national DHIS2. To effectively manage non-communicable diseases, a phased roadmap has been developed (Table 3). This roadmap includes targeted interventions that address financing, workforce capacity, policy frameworks, and data monitoring." 9. Consequences of Systemic Failures: Patient and Societal Impact The failure to restructure the healthcare system to meet the demands of the NCD epidemic carries severe consequences at both the individual (micro) and national (macro) levels. 9.1. Micro-Level Impact: Patient Care and Quality of Life 9.1.1. Health Literacy Gap The current systemic failure results in a profound health literacy gap among NCD patients. Data indicates that over 70% of individuals diagnosed with diabetes in urban settings have not received adequate education on managing their condition. This lack of self-management education is the direct antecedent to poor clinical outcomes, leading to increased rates of preventable complications such as cardiovascular disease, kidney failure, and amputations. Without continuous education, medication adherence falters, undermining any clinical intervention provided. 9.1.2. Psychological and Emotional Toll Chronic illness places a significant psychological and emotional burden on patients and their families, particularly in a context of limited support and extreme financial strain. The inability to manage a long-term condition effectively in a reactive health system leads to chronic feelings of helplessness and frustration. This emotional distress contributes to mental health issues like anxiety and depression, which are frequently neglected in NCD care but are intrinsically linked to poor adherence and management (especially when exacerbated by risk factors like Khat use). Systemic failures in NCD care extend beyond physical morbidity to compromise overall well-being and mental health stability. 9.2. Macro-Level Impact: Economic and Developmental Constraints 9.2.1. Lost Productivity and Human Capital Erosion At the macro-level, premature NCD mortality and morbidity severely diminish the productive workforce, resulting in the erosion of human capital. Chronic illness reduces worker availability and efficiency, directly hindering national development and poverty reduction efforts. The economic cost extends beyond direct healthcare expenditure, encompassing lost wages, reduced household income, and increased reliance on external aid, ultimately stalling economic recovery. 9.2.2. Perpetuation of Health Inequities The reliance on high Out-of-Pocket (OOP) payments and the fragmentation of care toward an unregulated private sector ensures that NCDs become a disease of poverty. The current system disproportionately affects the poor, who are least able to afford continuous care, medications, and the non-medical costs associated with chronic disease management. This reliance on user fees perpetuates health inequities, transforming NCDs from a health challenge into a fundamental driver of social and economic disparity. Without policy intervention that mitigates financial toxicity (such as VBC or risk pooling), the health system will continue to solidify and deepen existing social inequalities. 10. Conclusion and Strategic Recommendations 10.1. Summary of Key Findings and Thematic Synthesis The analysis confirms that Somalia’s health system stands at a critical juncture, facing a rapidly accelerating NCD burden (25-30% mortality share, 33% hypertension prevalence) that is structurally opposed by a health architecture optimized for acute care. The core conflict resides in the confluence of low public financing, high financial toxicity driven by FFS and catastrophic OOP payments, acute workforce scarcity (0.11 clinicians/1000) , and fragmented governance that prevents quality standardization and data collection. To achieve meaningful and sustainable improvements in health outcomes, the shift from a reactive, crisis-management approach to a proactive, long-term health management model is imperative. This transformation demands not only clinical interventions but fundamental structural, financial, and regulatory reforms that redefine how NCDs are perceived and managed in a fragile context. 10.2. Expanded Strategic Recommendations (Policy Prescriptions) Based on the synthesis of systemic barriers and evidence from regional models, the following five strategic recommendations form the core of the Value-Based Policy Roadmap for NCD control in Somalia: Revise Reimbursement Models (Financial Restructuring): The Federal Ministry of Health must mandate VBC pilot studies immediately, focusing on high-prevalence NCDs. The long-term policy goal is the institutionalization of outcome-based contracting (e.g., bundled payments for chronic care) to eliminate the volume incentive inherent in FFS and incentivize preventive care, thereby providing an essential layer of financial risk mitigation against catastrophic health expenditure. Invest in Integrated Primary Healthcare Infrastructure and Continuity: Strategic capital investment must prioritize equipping rural PHC centers with the necessary resources (essential NCD medications, diagnostic tools) and the implementation of standardized NCD-specific SOPs for continuous service delivery. This must be coupled with the establishment of reliable, two-way referral pathways to ensure that PHC can effectively manage chronic conditions and prevent unnecessary escalations to acute hospital care. Empower Communities and Address Unique Risk Factors: A significant expansion of the Community Health Worker network is required, coupled with funding for culturally sensitive, outcome-driven health literacy programs. Policy must include coordinated multi-sectoral interventions specifically targeting Khat use, recognizing its unique role as a critical behavioral risk factor that drives hypertension and complicates mental health integration. Strengthen Political and Institutional Capacity (Governance): The National NCD Policy must be finalized, adopted, and operationalized with clear implementation targets integrated into the HSSP III framework. Sustainable funding must be secured for regulatory bodies (e.g., NHPC) to enforce quality standards across the fragmented private sector. Furthermore, the establishment of transparent federal-state accountability frameworks tied to tangible NCD outcome targets is crucial to ensure equitable policy reach across the Federal Member States. Transform Health Workforce Education and Delivery: The health system must formally adopt and implement the WHO PEN and HEARTS technical packages using cascade training models, leveraging task-shifting to integrate NCD chronic care management into PHC. National medical curricula must be comprehensively overhauled to emphasize chronic disease management, patient education, and preventive care strategies, addressing the fundamental training deficiencies identified in the current workforce. Declarations Funding: The authors declare that no external funding was received for the development of this manuscript or the literature synthesis. Ethical Considerations: This study is based on a comprehensive review and synthesis of publicly available and grey literature. The study complies with ethical standards for research review and analysis, and no ethical approval was required as no human subjects, confidential patient data, or primary interventions were involved. Conflicts of Interest: The authors declare no conflicts of interest related to the subject matter, the analysis conducted, or the conclusions presented in this manuscript. Authors’ Contributions: All authors contributed substantially to the conception of the manuscript structure, the systematic review methodology, the synthesis of data, and the drafting and critical revision of the final policy report. Acknowledgements: The authors acknowledge the crucial work of public health agencies, international partners (WHO, Global Fund), and local government bodies whose reports and data provided the empirical foundation for this system analysis and policy roadmap. References African Health Observatory. (2022). Health Expenditure in Somalia . Global Burden of Disease Collaborative Network. (2024). Global Burden of Disease Study 2021 (GBD 2021) Results . Global Fund. (2021). Health System Assessment in Somalia . Kenya Health Information System. (2021). Impact of Value-Based Care Models . Marmot M, et al. (2019). The Health Gap: The Challenge of an Unequal World . Somali Ministry of Health. (2022). National Health Strategy Report . Somali Health and Demographic Survey. (2020). WHO. (2021). Health Systems in Africa: Challenges and Opportunities . World Health Organization. (2021). Share of deaths by broad cause. Somalia . World Health Organization. (2021). Global action plan for the prevention and control of noncommunicable diseases 2013–2030 . World Health Organization. (2021). WHO package of essential noncommunicable (PEN) disease interventions for primary health care . Abdi AM, Osman HM, Muhumed M. The Challenges of Somalia's Healthcare System in Addressing Non-Communicable Diseases: Understanding the Complex Solutions Needed (Original Manuscript). Abdirasak Mohamed A, et al. (2025). Challenges and Opportunities in Utilizing Secondary Data for Health Research in Somalia: A Focus on Health Management Information Systems (HMIS) . UNICEF/HISP-UIO. DHIS2 in Somalia Partnership . World Bank. (2021). Somalia: Improving Healthcare Services in Somalia (Damal Caafimaad Project) . Page MJ, et al. (2020). The PRISMA 2020 statement: an updated guideline for reporting systematic reviews . Moher D, et al. (2009). Preferred Reporting Items for Systematic reviews and Meta-Analyses: The PRISMA Statement . World Health Organization. (2021). WHO’s work on noncommunicable diseases . GBD 2021 DALY Collaborators. (2024). Global incidence, prevalence, years lived with disability (YLDs), disability-adjusted life-years (DALYs) . Kruk ME, et al. (2022). The financial burden of noncommunicable diseases in sub-Saharan Africa: a systematic analysis . UNDP Somalia. (2023). National Transformation Plan (NTP) 2025–2029 Roundtable . SDC-funded PSPH Program. (2024). Private Sector Partnerships in Health: Mobilizing private healthcare providers in forming unions . GHDX. (2021). Death rate from cardiovascular diseases in Somalia . Al Khalili R. (2024). Somaliland’s Khat Conundrum . Abate T, et al. (2021). Prevalence and factors associated with Khat chewing among the general population . Somalia Federal Government. (2022). National Health Sector Strategic Plan 2022-2026 (HSSP III) . World Diabetes Foundation. (2023). Supporting the development of standard operating procedures for NCD medicines and technologies in Somalia . WHO. (2022). WHO HEARTS technical package . UNICEF Somalia. (2020). Harmonised Community Health Workers Training Manual . GBD 2021 Mortality Collaborators. (2024). Estimates of global mortality and years of life lost due to COVID-19 . Naimoli J, et al. (2022). Task shifting for non-communicable disease management in conflict-affected settings . World Bank. (2022). Somalia: Current health expenditure per capita . GRADE Working Group. (2004). Grading quality of evidence and strength of recommendations . Witter S, et al. (2022). Implementation of Value-Based Health Care in low-resource settings . Ghana VBC Investigators. (2024). Value-Based Care intervention for poorly controlled hypertension in Ghana . van der Merwe L, et al. (2020). Measuring health outcomes in Africa: Patient-reported outcome measures (PROMs) protocol . Additional Declarations The authors declare no competing interests. Supplementary Files 13.Appendices.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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Introduction: NCDs in Fragile State Settings","content":"\u003ch3\u003e1.1. The Global Imperative: NCDs, Sustainable Development, and Fragile Contexts\u003c/h3\u003e\n\u003ch4\u003e1.1.1. NCDs and the Global Burden of Disease (GBD)\u003c/h4\u003e\n\u003cp\u003eGlobally, the epidemiological transition continues to shift the predominant causes of morbidity and mortality toward chronic, non-communicable conditions. Projections indicate that NCDs will be responsible for approximately 70% of all deaths worldwide by 2030. For countries like Somalia, which have historically focused resources and policy on infectious and maternal/child health issues, this transition represents a fundamental threat to public health stability.\u003c/p\u003e\n\u003cp\u003eTo accurately quantify the impact of NCDs, analysis must move beyond simple mortality statistics to comprehensive metrics of health loss. The Disability-Adjusted Life Year (DALY) calculation, which represents the sum of Years of Life Lost (YLLs) due to premature mortality and Years Lived with Disability (YLDs), serves as a critical indicator. In a context like Somalia, where NCDs contribute significantly to long-term impairment (such as diabetes-related complications or hypertension-related stroke), the DALY burden underscores the immense strain placed on productive human capital and family resources, demonstrating that the burden extends far beyond immediate fatality counts.\u003c/p\u003e\n\u003ch4\u003e1.1.2. The Double Burden of Disease in Fragile and Conflict-Affected States (FCAS)\u003c/h4\u003e\n\u003cp\u003eSomalia, classified as a fragile and conflict-affected state, manages the complex challenge of a \"double burden\" of disease. Historically, the nation has grappled with a high incidence of communicable, maternal, perinatal, and nutritional conditions, which accounted for an estimated 63.8% of deaths in 2021. This acute burden demands emergency preparedness and intervention-focused medical responses.\u003c/p\u003e\n\u003cp\u003eHowever, recent trends confirm a rapid increase in chronic disease prevalence. NCDs now represent a substantial cause of death, contributing between 25.1% and 30% of all fatalities. This rapid shift presents a significant challenge: the existing health system infrastructure and financial architecture are optimized for acute, infectious disease responses, not the continuous, infrastructure-heavy care, long-term monitoring, and preventative strategies required for NCD management. The very fragility that characterizes the system, often created by prolonged conflict and instability, exacerbates NCD risk factors (e.g., stress, poor diet, limited access to stable health services) while simultaneously inhibiting the implementation of the long-term system investments necessary for chronic care management. This creates a critical paradox wherein the operational environment that generates NCD risks actively prevents sustainable systemic solutions, necessitating a resilience-centric approach to policy design.\u003c/p\u003e\n\u003ch4\u003e1.1.3. NCD Management as a Precondition for SDG Achievement\u003c/h4\u003e\n\u003cp\u003eEffective NCD management is not merely a sectoral health goal; it is foundational to achieving the broader Sustainable Development Goals (SDGs). Specifically, NCD control is mandated under SDG 3.4 (to reduce premature mortality from NCDs by one-third by 2030). Failure to achieve this target directly compromises progress toward poverty eradication (SDG 1.1.1).\u003c/p\u003e\n\u003cp\u003eChronic illnesses impose recurrent, often catastrophic, health expenditures on affected households. The financial shock associated with NCD treatment, prolonged hospitalizations, and lost income drives families into extreme poverty. Therefore, strengthening NCD care, especially through preventative strategies and chronic management at the primary healthcare (PHC) level, becomes a crucial mechanism for financial protection and poverty alleviation. The policy roadmap proposed herein views NCD management as an essential component of national development and long-term stability, not just a clinical endeavor.\u003c/p\u003e\n\u003ch3\u003e1.2. Geo-Political and Health System Context of Somalia\u003c/h3\u003e\n\u003ch4\u003e1.2.1. Historical Background and Healthcare System Fragmentation\u003c/h4\u003e\n\u003cp\u003eSomalia’s health system has been severely weakened and fragmented by decades of civil conflict and political instability. The resulting environment is characterized by diverse, often uncoordinated, service providers, including private actors, non-governmental organizations (NGOs), and governmental institutions.\u003c/p\u003e\n\u003cp\u003eCurrent government efforts are guided by the National Health Sector Strategic Plan (HSSP III, 2022–2026), which provides the overarching policy direction for the health sector. However, the successful implementation of this plan, particularly concerning complex challenges like NCDs, depends heavily on overcoming deep-seated issues of fragmentation and resource scarcity that have plagued the sector for decades.\u003c/p\u003e\n\u003ch4\u003e1.2.2. Defining the Crisis\u003c/h4\u003e\n\u003cp\u003eThe scale of the crisis is quantifiable through key indicators. Somalia’s Universal Health Coverage (UHC) index remains critically low, estimated at only 25%. This implies that three-quarters of the population lacks access to essential health services without facing potentially crippling financial hardship. Compounding this, the health workforce density stands at an alarmingly low 0.11 clinicians per 1,000 population.\u003c/p\u003e\n\u003cp\u003eThe rising NCD burden, therefore, should be defined not only as a clinical or public health challenge but as a major developmental and security risk. An unhealthy population, burdened by chronic disease and financial toxicity, compromises national resilience and socio-economic progress. Given the country’s inherent institutional weakness, the NCD threat must be addressed through strategic, evidence-based interventions that prioritize system resilience.\u003c/p\u003e\n\u003ch3\u003e1.3. Rationale and Structure of the Manuscript\u003c/h3\u003e\n\u003ch4\u003e1.3.1. Policy Gap Analysis\u003c/h4\u003e\n\u003cp\u003eA critical policy gap exists in Somalia regarding comprehensive NCD management. Compared to neighboring countries like Kenya and Ethiopia, which have made significant advancements in developing robust NCD management frameworks, Somalia lags significantly. These regional peers have successfully implemented national policies aimed at integrating NCD care into primary healthcare and scaling community health initiatives. Somalia’s fragmentation, coupled with a reactive budgeting approach, inhibits the development of a cohesive national strategy, resulting in effective interventions often remaining isolated and failing to reach the rural populations most in need.\u003c/p\u003e\n\u003ch4\u003e1.3.2. Objectives and Thesis\u003c/h4\u003e\n\u003cp\u003eThis article aims to explore the challenges posed by the rising NCD epidemic in Somalia through a detailed analysis of structural barriers, organized around the WHO Health Systems Building Blocks. The ultimate goal is to deconstruct these systemic challenges and propose a comprehensive, Value-Based Care (VBC) centered policy roadmap. This roadmap focuses on integrating NCD prevention, diagnosis, and long-term chronic management effectively into the Primary Healthcare (PHC) framework, thereby supporting sustainable health system transformation in a fragile setting.\u003c/p\u003e"},{"header":"2. Methodology and Analytical Framework","content":"\u003ch3\u003e2.1. Study Design: A Mixed-Methods Policy Synthesis Approach\u003c/h3\u003e\n\u003cp\u003eThe study adopted a policy synthesis approach, utilizing a systematic review methodology to analyze the heterogeneous data available concerning NCDs and health systems in Somalia. Given the scarcity of primary intervention studies in conflict-affected settings, this approach allowed for the comprehensive assessment and thematic integration of epidemiological data, qualitative assessments of systemic barriers, and policy documentation.\u003c/p\u003e\n\u003ch4\u003e2.1.1. Rationale for Systematic Literature Review\u003c/h4\u003e\n\u003cp\u003eThe systematic literature review focused on studies published in English over the last decade that specifically address NCD prevalence, risk factors, health system challenges, and policy interventions within the Somali context. This timeframe captures the critical period during which Somalia experienced its rapid epidemiological transition toward chronic conditions, providing the most relevant data for policy formulation.\u003c/p\u003e\n\u003ch4\u003e2.1.2. Search Strategy and Databases\u003c/h4\u003e\n\u003cp\u003eThe primary search strategy employed a combination of key terms related to the condition (\"Non-Communicable Diseases,\" \"Hypertension,\" \"Diabetes\"), the geographic location (\"Somalia,\" \"Somaliland,\" \"Horn of Africa\"), and systemic barriers (\"health system challenges,\" \"fee-for-service,\" \"primary healthcare integration,\" \"fragile states\"). Databases utilized included PubMed, Scopus, and Google Scholar. To ensure the inclusion of critical governmental and organizational perspectives often unavailable in peer-reviewed literature, the search was supplemented by targeted searches of grey literature, including reports from the WHO, the Global Fund, and the Somali Ministry of Health.\u003c/p\u003e\n\u003ch4\u003e2.1.3. Selection Criteria and Screening\u003c/h4\u003e\n\u003cp\u003eStudies were included if they provided empirical data on NCD prevalence, addressed health service delivery barriers specific to NCDs, or analyzed policy and financing mechanisms within the Somali or closely related Fragile State contexts. Exclusion criteria included studies not published in English, reports older than 10 years, or studies where the findings could not be specifically contextualized to the Somali health system. Thematic relevance was prioritized during screening.\u003c/p\u003e\n\u003ch3\u003e2.2. Data Extraction, Synthesis, and Quality Appraisal\u003c/h3\u003e\n\u003ch4\u003e2.2.1. PRISMA Alignment and Flow Diagram\u003c/h4\u003e\n\u003cp\u003eAlthough the study is a policy review rather than a meta-analysis of intervention efficacy, the methodology was aligned with the PRISMA 2020 (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. This commitment to transparency requires a detailed documentation of the study selection process, typically presented through a PRISMA flow diagram (Appendix A). This ensures clarity in reporting why studies were included or excluded, lending robust validation to the synthesized policy conclusions.\u003c/p\u003e\n\u003ch4\u003e2.2.2. Quality Appraisal Instruments\u003c/h4\u003e\n\u003cp\u003eRigor in synthesizing evidence requires a formal appraisal of the methodological quality and certainty of the included documentation. For prevalence data derived primarily from cross-sectional or observational studies, the \u003cstrong\u003eNewcastle-Ottawa Scale (NOS)\u003c/strong\u003e was applied to assess quality metrics such as selection, comparability, and outcome reporting.\u003c/p\u003e\n\u003cp\u003eTo assess the strength of the resulting policy recommendations, the \u003cstrong\u003eGRADE (Grading of Recommendations, Assessment, Development, and Evaluations)\u003c/strong\u003e system was utilized. GRADE provides a structured approach for evaluating the overall certainty of evidence and determining the strength of subsequent policy prescriptions, moving the manuscript beyond a simple narrative review to a credible foundation for national policy development.\u003c/p\u003e\n\u003ch4\u003e2.2.3. Thematic Synthesis\u003c/h4\u003e\n\u003cp\u003eData extraction focused on identifying key barriers and opportunities within the established framework of the \u003cstrong\u003eWHO Health Systems Building Blocks\u003c/strong\u003e. This framework ensures a comprehensive analysis covering: Service Delivery, Health Workforce, Health Information Systems, Medical Products and Technologies, Health Financing, and Leadership/Governance. Utilizing this universally recognized \u003cem\u003ea priori\u003c/em\u003e structure allows for the systematic comparison of Somalia's NCD challenges across critical system components and facilitates the development of targeted, integrated policy solutions.\u003c/p\u003e\n\u003cp\u003eThe analysis revealed that systemic instability, particularly in governance and financing, creates quality disparities and bottlenecks for implementation. Specifically, the fragmented, private-dominant nature of service delivery operating under weak regulation creates inherent inconsistencies in the quality of NCD care. This lack of standardization is fundamentally antithetical to the continuity and predictability required for Value-Based Care (VBC). Therefore, system-wide governance strengthening and standardization must run parallel to, or precede, VBC implementation to ensure that quality is uniformly delivered across the provider network.\u003c/p\u003e"},{"header":"3. Epidemiological Transition: Quantifying the NCD Burden","content":"\u003ch3\u003e3.1. Current Prevalence and Disease Profile\u003c/h3\u003e\n\u003cp\u003eThe burden of NCDs in Somalia has reached a critical threshold, demanding resources and systemic attention comparable to communicable diseases. The current data reveals alarmingly high prevalence rates for major NCDs, often linked to lifestyle changes and the effects of chronic instability.\u003c/p\u003e\n\u003ch4\u003e3.1.1. Hypertension and Diabetes\u003c/h4\u003e\n\u003cp\u003eHypertension and Type 2 Diabetes Mellitus are the most prevalent NCDs and represent the immediate threat to the adult population. According to the Somali Health and Demographic Survey (2020), hypertension affects a staggering 33% of the adult population. The prevalence of diabetes stands at approximately 20%. These conditions are silent epidemics that often lead to severe complications, including cardiovascular diseases, stroke, and kidney failure, placing predictable yet overwhelming demand on tertiary care facilities. The high prevalence underscores an urgent need for widespread population screening and the integration of chronic disease management into every level of care.\u003c/p\u003e\n\u003ch4\u003e3.1.2. Burden Quantified: Mortality and DALYs\u003c/h4\u003e\n\u003cp\u003eWhile Somalia historically reported that communicable, maternal, perinatal, and nutritional conditions accounted for 63.8% of deaths, the share attributable to NCDs has risen significantly, estimated at 25.1% in 2021. Other estimates place the NCD mortality share closer to 30% of all fatalities. This rapid shift demonstrates an incomplete, yet highly damaging, epidemiological transition.\u003c/p\u003e\n\u003cp\u003eThe significance of this burden is best understood through the calculation of Disability-Adjusted Life Years (DALYs). DALYs capture the years of healthy life lost due to premature death and disability. For Somalia, the rising NCD DALY rates signify an erosion of human capital\u0026mdash;a loss of productive life years that hampers economic and social recovery. Analyzing DALYs, rather than simple mortality, illustrates that NCDs are chronic drivers of disability, demanding long-term care investments that the existing acute-focused system is structurally unprepared to provide.\u003c/p\u003e\n\u003ch4\u003e3.1.3. Other Key NCDs\u003c/h4\u003e\n\u003cp\u003eBeyond diabetes and hypertension, Somalia faces a rising incidence of other NCDs, including various cancers, cardiovascular diseases (CVD), and chronic respiratory diseases. While data collection remains fragmented, these conditions contribute substantially to the overall DALY burden. Targeted screening and prevention programs, particularly for common cancers and chronic lung conditions, must be factored into the national NCD policy to manage the full scope of the disease burden.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1: Proposed NCD Burden Profile in Somalia (Estimated)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis table presents an estimated profile of the burden of non-communicable diseases (NCDs) in Somalia, detailing prevalence rates, attributable mortality shares, DALY rate contributions relative to the Africa region average, and primary behavioral risk factors associated with each condition.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"656\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNCD Indicator\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrevalence (Adult Population)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAttributable Mortality Share (2021 Est.)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDALY Rate Contribution (Relative to Africa Region Average)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrimary Behavioral Risk Factors\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eHypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e~33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eHigh (CVD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eKhat use, high salt diet, urbanization\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eDiabetes Mellitus (Type 2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e~20%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eUnhealthy diet, physical inactivity\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eAll NCDs (Total)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e~25.1% - 30%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eCritically Significant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eTobacco, Khat, Diet, Insufficient physical activity\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eUnderstanding the burden of non-communicable diseases in Somalia is crucial for effective health planning. Table 1 outlines the estimated NCD burden profile, including prevalence, mortality, and key behavioral risk factors.\u0026quot;\u003c/p\u003e\n\u003ch3\u003e3.2. Socio-Ecological and Behavioral Risk Factors (The Somali Context)\u003c/h3\u003e\n\u003cp\u003eThe growing NCD burden is driven by behavioral and environmental factors unique to the Somali context, requiring specialized and culturally sensitive policy responses.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2.1. The Unique Role of Khat Chewing (A Major Policy Target)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKhat (\u003cem\u003eCatha edulis\u003c/em\u003e) chewing is a pervasive behavioral risk factor that demands specific policy attention due to its widespread cultural and economic roots. News reports and field observations indicate that up to 90% of adult males and 58% overall prevalence in affected populations regularly chew the stimulant.\u003c/p\u003e\n\u003cp\u003eThe health consequences are significant and directly linked to core NCDs. Khat use is strongly correlated with hypertension; a study in Hargeisa found that 53.5% of khat chewers reported Grade 1 hypertension, and 36.4% reported prehypertension. Chemically similar to amphetamine, cathinone and cathine, the active compounds in Khat, place significant strain on the cardiovascular system. Furthermore, excessive Khat use creates critical intersection points between NCDs and mental health, leading to severe mental disabilities, including anxiety, depression, and psychosis. Patients struggling with mental health issues are often non-adherent to NCD treatment regimens, creating a vicious cycle of poor outcomes.\u003c/p\u003e\n\u003cp\u003eEffective NCD policy must therefore address Khat not just as a health behavior but as a complex social determinant of health. Its pervasive use drives hypertension and compromises mental health, further straining the already weak capacity to manage chronic diseases. This necessitates a multi-sectoral approach involving health, commerce (taxation/regulation), and agriculture ministries to integrate cessation and mental health support directly into NCD primary care protocols.\u003c/p\u003e\n\u003ch4\u003e3.2.2. Urbanization, Diet, and Physical Activity\u003c/h4\u003e\n\u003cp\u003eRapid urbanization across Somalia has initiated classic epidemiological shifts observed worldwide. Urban living often involves changes in dietary patterns, leading to increased consumption of processed foods high in sugar, salt, and unhealthy fats. Simultaneously, urbanization often reduces occupational and leisure-time physical activity. These changes align with the recognized global risk factors for NCDs, including raised blood pressure, raised blood glucose, and overweight/obesity.\u003c/p\u003e\n\u003ch4\u003e3.2.3. Environmental and Humanitarian Context\u003c/h4\u003e\n\u003cp\u003eOngoing instability, recurring conflict, and vulnerability to climate shocks (e.g., drought, flooding) exacerbate NCD risk factors. Climate-induced displacement and chronic humanitarian crises lead to food insecurity, often resulting in poor nutritional status, stress, and extremely limited access to stable, continuous healthcare services required for chronic conditions. Policy must embed conflict-sensitive principles to ensure that NCD adaptation measures do not worsen social or political tensions and are resilient against recurrent crises.\u003c/p\u003e"},{"header":"4. Pillar 1: Fragmentation and Governance Failures","content":"\u003ch3\u003e4.1. Fragmentation of Service Delivery\u003c/h3\u003e\n\u003ch4\u003e4.1.1. Private Sector Dominance and Regulatory Vacuum\u003c/h4\u003e\n\u003cp\u003eThe Somali health system is overwhelmingly dependent on the private sector, which delivers over 80% of healthcare services. While the private sector provides essential coverage in a resource-scarce environment, this dominance is problematic when coupled with a nascent regulatory framework. Institutions such as the National Health Professionals Council (NHPC) are still developing capacity and face persistent resource constraints, undermining their ability to enforce standards effectively.\u003c/p\u003e\n\u003cp\u003eThis lack of comprehensive regulatory oversight leads to inconsistent standards of NCD care across facilities, hindering standardized protocol implementation. The fragmentation means hospitals, clinics, and diagnostic centers often operate in isolation, prioritizing competition over collaboration, which severely complicates efforts to implement system-wide improvements like VBC models. This structural disunity prevents providers from leveraging collective bargaining power for essential resources, such as pharmaceuticals, or advocating for meaningful policy reforms.\u003c/p\u003e\n\u003ch4\u003e4.1.2. The Failure of Referral Systems\u003c/h4\u003e\n\u003cp\u003eThe absence of functional, standardized referral pathways poses a major operational barrier to providing continuous NCD care. For chronic conditions that require long-term follow-up and specialized intervention only when necessary, ineffective referral systems are detrimental. Many individuals diagnosed with NCDs do not receive the necessary follow-up care or timely specialist consultation, which significantly increases the likelihood of health deterioration and preventable complications.\u003c/p\u003e\n\u003cp\u003eThis dysfunction forces patients into a cycle of crisis management, where treatable chronic conditions escalate rapidly into acute emergencies, often requiring expensive hospitalization in tertiary centers rather than manageable care at the primary level. The resulting congestion and expenditure drain resources from the entire system.\u003c/p\u003e\n\u003ch4\u003e4.1.3. Institutional Barriers to Scaling\u003c/h4\u003e\n\u003cp\u003eEven where promising pilot programs for NCD management demonstrate efficacy\u0026mdash;for example, community health initiatives in urban centers\u0026mdash;they frequently remain isolated successes. There is a critical lack of national frameworks and coordinated efforts necessary to replicate or fund these successful initiatives on a broader scale. This institutional deficit means effective interventions fail to reach rural populations where the need for NCD education and management is equally pressing. Addressing this requires formalized coordination and clear mechanisms for disseminating successful practices across the Federal Member States, overcoming fragmented regional implementation.\u003c/p\u003e\n\u003ch3\u003e4.2. Challenges in Health Governance and Policy\u003c/h3\u003e\n\u003ch4\u003e4.2.1. Resource Constraints and Regulatory Oversight\u003c/h4\u003e\n\u003cp\u003eRobust governance is non-negotiable for system-level reform. Regulatory discussions concerning the NHPC highlight persistent resource constraints that limit its efficacy in overseeing and professionalizing the health workforce. Without sustainable funding and political empowerment, the NHPC cannot effectively enforce standards for NCD practitioners or mandate participation in quality improvement and data reporting efforts, leaving the majority of the fragmented private market unchecked.\u003c/p\u003e\n\u003ch4\u003e4.2.2. Policy Development Gaps\u003c/h4\u003e\n\u003cp\u003eThe overarching National Health Sector Strategic Plan (HSSP III) provides direction, but operational gaps remain. A critical necessity is the finalization and robust implementation of a cohesive national NCD policy. Furthermore, the lack of standardized Standard Operating Procedures (SOPs) for key logistical areas, such as the handling, distribution, quantification, and forecasting of NCD medicines and technologies, undermines the reliability of chronic care provision. Without these standardized protocols, the quality and cost-effectiveness of NCD treatment cannot be assured, making continuous care impossible.\u003c/p\u003e\n\u003ch4\u003e4.2.3. Federal-State Accountability Frameworks\u003c/h4\u003e\n\u003cp\u003eSomalia\u0026rsquo;s federal structure introduces complexity regarding policy implementation. Ensuring uniform and equitable NCD policy implementation across all Federal Member States requires strong federal-state accountability frameworks. Policy success depends on training policymakers and health administrators to understand NCD management complexities and the principles of VBC , ensuring that resource allocation and regulatory enforcement are harmonized across disparate regions.\u003c/p\u003e"},{"header":"5. Pillar 2: Financing Deficits and Economic Catastrophe","content":"\u003cp\u003eThe structure of health financing in Somalia poses the most significant systemic barrier to NCD management, driving economic hardship and inefficiency.\u003c/p\u003e\n\u003ch3\u003e5.1. Analysis of Current Health Expenditure and Out-of-Pocket Payments\u003c/h3\u003e\n\u003ch4\u003e5.1.1. Insufficient Public Health Investment\u003c/h4\u003e\n\u003cp\u003eThe current health budget allocation reflects a reactive approach to public health crises, rather than a proactive investment in prevention. Reports indicate that less than 10% of health expenditures focus on preventive services. This limited investment starves public health education, community screening programs, and other essential activities required to manage NCD risk factors effectively. This reactive budgeting approach fosters a continuous cycle of crisis management, ensuring that resources are repeatedly allocated to expensive acute interventions instead of sustainable prevention strategies.\u003c/p\u003e\n\u003ch4\u003e5.1.2. Out-of-Pocket Expenditure (OOP) and Financial Toxicity\u003c/h4\u003e\n\u003cp\u003eIn the absence of a robust national health insurance or risk-pooling mechanism, the Somali health system relies heavily on Out-of-Pocket (OOP) payments. This reliance is the primary driver of medical impoverishment. In Sub-Saharan Africa, where financing systems struggle with prepayment contributions, the incidence of catastrophic health expenditure (CHE) is high. Crucially, the evidence shows that NCDs are a major driver of these costs; about a quarter of households affected by a noncommunicable disease incurred CHE, typically defined as health expenditure exceeding 10% of total household expenditure. This figure is substantially higher than for the general population.\u003c/p\u003e\n\u003cp\u003eThe components of this financial toxicity are complex, encompassing not only the direct costs of treatment, but also non-medical expenditure (e.g., travel to distant clinics for follow-up) and the pervasive issue of lost income due to prolonged illness or hospitalization. Even in instances where specific disease treatments (like for HIV/AIDS or TB) are exempted from OOP payments, households still incur CHE due to these indirect costs. This underscores that addressing the financial burden of NCDs requires systemic reform that goes beyond simple exemptions for specific drugs.\u003c/p\u003e\n\u003ch4\u003e5.1.3. The Economic Burden of NCDs\u003c/h4\u003e\n\u003cp\u003eAt the macro-level, the economic impact of NCDs is substantial, straining the fragile economy. Reports highlight that NCDs could cost the Somali economy billions each year. This macro-level financial drain results from the cumulative cost of increased hospital admissions, prolonged treatment durations, and the need for expensive specialized care, all of which divert limited resources from other critical developmental areas. The resulting lost productivity due to premature mortality and morbidity further erodes the nation's human capital, contributing to a cycle of poverty and hampering national development goals.\u003c/p\u003e\n\u003ch3\u003e5.2. The Case for Shifting to Value-Based Care (VBC)\u003c/h3\u003e\n\u003cp\u003eThe evidence of FFS failure and catastrophic health expenditure necessitates a paradigm shift in health financing. Value-Based Care (VBC) presents a foundational opportunity for systemic reform.\u003c/p\u003e\n\u003ch4\u003e5.2.1. Deconstruction of Fee-for-Service (FFS) Failures\u003c/h4\u003e\n\u003cp\u003eThe Fee-for-Service (FFS) model, currently prevalent in Somalia, directly contributes to poor NCD outcomes. By incentivizing the quantity of services (procedures, visits) over the quality of care and patient outcomes, FFS discourages essential preventive measures, early detection, and continuous chronic care management. This model ensures high cost without guaranteeing improvement in long-term patient health, particularly for conditions like hypertension and diabetes that require sustained adherence and lifestyle management.\u003c/p\u003e\n\u003ch4\u003e5.2.2. Definition and Application of VBC in LMICs\u003c/h4\u003e\n\u003cp\u003eValue-Based Care (VBC) is a healthcare delivery model that shifts focus from service volume to patient outcomes, quality of care, and cost optimization. Under VBC, providers are incentivized to keep populations healthy and manage chronic diseases effectively, aligning the financial interests of providers with the long-term health interests of patients.\u003c/p\u003e\n\u003cp\u003eImportantly, VBC is not restricted to high-income settings. Evidence from other low- and middle-income countries (LMICs) confirms its feasibility, particularly when implemented incrementally. Case studies in Africa have shown that a cohort-based approach to VBC, focusing on defined outcome metrics at predictable costs per enrolled person, can successfully initiate health system restructuring from an output-driven model to a value-based financing model. For example, pilot programs in Ghana testing VBC interventions for hypertension demonstrated improved clinical outcomes and patient satisfaction.\u003c/p\u003e\n\u003ch4\u003e5.2.3. Financial Protection via VBC\u003c/h4\u003e\n\u003cp\u003eThe analysis suggests that VBC serves as the most immediate domestic strategy for financial risk management in Somalia. Since NCDs cause recurrent, cumulative financial shocks (CHE) , shifting to outcome-based reimbursement provides a structure to mitigate financial risk and reduce health-related poverty, even before a full national health insurance scheme is feasible. By prioritizing preventative care and successful long-term chronic management, VBC reduces the frequency and severity of costly acute complications, thereby acting as an essential mechanism for financial protection against catastrophic health expenditure.\u003c/p\u003e"},{"header":"6. Pillar 3: Workforce Capacity and Integrated Service Delivery","content":"\u003cp\u003eThe inability to effectively address NCDs is critically dependent on the scarcity and preparedness of the health workforce, which demands innovative delivery models.\u003c/p\u003e\n\u003ch3\u003e6.1. The Critical Human Resource Crisis\u003c/h3\u003e\n\u003ch4\u003e6.1.1. Quantifying Workforce Scarcity\u003c/h4\u003e\n\u003cp\u003eSomalia faces an acute human resource crisis, with a critical health workforce density of only 0.11 clinicians per 1,000 population. This density is far below the minimum recommended global threshold and is particularly problematic in rural districts, where basic primary health coverage remains the most urgent barrier to UHC. This extreme scarcity threatens to undermine any policy expansion, including the establishment of new physical infrastructure.\u003c/p\u003e\n\u003ch4\u003e6.1.2. Training Deficiencies\u003c/h4\u003e\n\u003cp\u003eCurrent medical training programs exacerbate the crisis by clinging to an outdated curriculum emphasizing acute care and trauma management. This neglect of essential components of chronic disease management and prevention means the workforce is ill-prepared to address the long-term, complex nature of NCDs. Surveys of healthcare professionals reveal that many feel inadequately trained to manage chronic conditions, highlighting a significant gap between the reality of the disease burden and professional competence.\u003c/p\u003e\n\u003ch4\u003e6.1.3. The Specialist Gap\u003c/h4\u003e\n\u003cp\u003eThe lack of specialized NCD practitioners (e.g., cardiologists, endocrinologists) places an unsustainable burden on general practitioners and forces reliance on expensive, foreign-trained staff or complex referral chains that often fail. This specialist gap underscores the need for alternative, non-physician-led models of care delivery capable of managing routine NCD treatment and prevention.\u003c/p\u003e\n\u003ch3\u003e6.2. Strategic Task-Shifting and PHC Integration\u003c/h3\u003e\n\u003ch4\u003e6.2.1. Task-Shifting as an Innovative Solution\u003c/h4\u003e\n\u003cp\u003eTo maximize the utilization of the scarce human capital, \u003cstrong\u003etask shifting\u003c/strong\u003e—defined by the WHO as the reallocation of tasks from highly experienced professionals (e.g., physicians) to those with more limited training (e.g., nurses, CHWs)—is essential. Task shifting allows the existing health workforce to be utilized more efficiently, making it a powerful tool for service expansion in fragile contexts.\u003c/p\u003e\n\u003cp\u003eStudies in LMICs suggest that task shifting can improve nurse satisfaction and retention, which is critical given the unprecedented migration of trained professionals to higher-income countries. Therefore, the formalization of task sharing roles for NCD management offers dual benefits: expanding care capacity and enhancing workforce stability.\u003c/p\u003e\n\u003ch4\u003e6.2.2. WHO PEN and HEARTS Adaptation\u003c/h4\u003e\n\u003cp\u003eThe adoption and adaptation of globally validated, simplified protocols are central to integrating NCD care into PHC. The \u003cstrong\u003eWHO Package of Essential Non-Communicable Disease Interventions (PEN)\u003c/strong\u003e provides a crucial framework for diagnosis and management in low-resource settings. Building upon this, the \u003cstrong\u003eWHO HEARTS Technical Package\u003c/strong\u003e offers six practical modules and an implementation guide focused on strengthening cardiovascular disease (CVD) management, including standardized protocols for hypertension and diabetes detection and treatment.\u003c/p\u003e\n\u003cp\u003eThese models must be adapted and implemented through cascade training systems, focusing on transferring NCD management skills to nurses and community health workers (CHWs) at the PHC level. This decentralized approach is the most realistic path to achieving wide-scale coverage in a country with low specialist density.\u003c/p\u003e\n\u003ch4\u003e6.2.3. Empowering Community Health Workers (CHWs)\u003c/h4\u003e\n\u003cp\u003eCommunity Health Worker (CHW) programs are pivotal for closing the rural access gap and enhancing health literacy. Policy must prioritize the expansion of CHW programs, with specific emphasis on female CHWs and deployment incentives for rural districts.\u003c/p\u003e\n\u003cp\u003eCHWs, utilizing harmonized training manuals, are uniquely positioned to bridge the gap between clinical care and community practice. Their roles must be formalized to include NCD prevention education, healthy lifestyle counseling (using models like the 5As brief intervention), promoting medication adherence, and facilitating early diagnosis. Furthermore, integrating these roles under a Value-Based Care framework, which rewards improved patient outcomes (e.g., good blood pressure control achieved at the community level), can offer dual benefits: improved NCD control and increased stability and retention of the scarce health workforce by rewarding performance.\u003c/p\u003e"},{"header":"7. Pillar 4: Data, Monitoring, and Value-Based Metrics","content":"\u003cp\u003eThe successful transition to VBC and evidence-based NCD policy is fundamentally dependent on robust data collection, yet the current health information systems present a major policy bottleneck.\u003c/p\u003e\n\u003ch3\u003e7.1. Assessment of Health Management Information Systems (HMIS)\u003c/h3\u003e\n\u003ch4\u003e7.1.1. DHIS2 Status and Limitations\u003c/h4\u003e\n\u003cp\u003eThe national Health Management Information System (HMIS) in Somalia is based on the District Health Information Software 2 (DHIS2), which serves as the national data backbone for areas like disease surveillance and immunization. However, the DHIS2 system is nascent and plagued by severe data quality and accessibility challenges.\u003c/p\u003e\n\u003cp\u003eReporting rates are critically low, hovering around 50% of health facilities, with some regions failing to submit reports for months at a time due to infrastructure, communication, and human resource constraints. Furthermore, a health system assessment revealed that over 60% of facilities lack a reliable system for collecting data. This deficiency compromises the government\u0026apos;s ability to track health outcomes reliably.\u003c/p\u003e\n\u003ch4\u003e7.1.2. Impact on Evidence-Based Policy\u003c/h4\u003e\n\u003cp\u003eFragmented and unreliable data severely impede effective decision-making. Without robust data, it is nearly impossible to track NCD outcomes (e.g., patient adherence, complication rates), identify local epidemiological trends, or implement evidence-based policies that respond to regional needs.\u003c/p\u003e\n\u003cp\u003eThis data inadequacy is not merely an operational challenge; it functions as a policy bottleneck for VBC implementation. VBC payment models are inherently data-dependent, rewarding performance based on measured outcomes. If the underlying HMIS cannot reliably capture these metrics, VBC cannot be institutionalized effectively, leading to paralysis in policy reform.\u003c/p\u003e\n\u003ch3\u003e7.2. Framework for Value-Based Outcome Measurement\u003c/h3\u003e\n\u003cp\u003eTo overcome the data bottleneck, a phased and adaptive strategy for measuring value is required, starting with non-digital solutions where necessary.\u003c/p\u003e\n\u003ch4\u003e7.2.1. Defining NCD Value\u003c/h4\u003e\n\u003cp\u003eThe shift requires moving away from tracking simple output measures (number of clinic visits) to defining and measuring clinical outcomes that truly matter, such as \\text{HbA}_{1\\text{c}} control for diabetes, consistent blood pressure control for hypertension, and patient experience/satisfaction. These metrics are the foundation upon which VBC reimbursement models are built.\u003c/p\u003e\n\u003ch4\u003e7.2.2. Adapting Patient-Reported Outcome Measures (PROMs) for Somalia\u003c/h4\u003e\n\u003cp\u003eIn low-literacy settings like Somalia, standard patient-reported outcome measures (PROMs) may not be fully appropriate due to the high rate of patients (over 70% of diabetes patients in urban areas) lacking adequate education on managing their condition. Cultural barriers and low literacy require innovative approaches.\u003c/p\u003e\n\u003cp\u003eThe strategic use of \u003cstrong\u003eObserver-Reported Outcome Measures (ObSROMs)\u003c/strong\u003e, where a trained healthcare provider (like a nurse or CHW) assesses the patient\u0026apos;s functional status and adherence, can compensate for low literacy levels. Concurrently, culturally adapted and translated PROMs should be developed to capture the patient\u0026apos;s viewpoint, particularly on quality of life and treatment satisfaction, leveraging the local knowledge of CHWs to ensure relevance and validity.\u003c/p\u003e\n\u003ch4\u003e7.2.3. Incremental Implementation\u003c/h4\u003e\n\u003cp\u003eTo avoid overwhelming the fragile DHIS2 system, VBC implementation should be incremental. Pilot programs should start with a small cohort of established PHC centers, focusing on collecting standardized data for simplified metrics: adherence rates, complication frequency (e.g., incidence of stroke or foot ulcers), and clinical control targets. This cohort-based approach allows for iterative learning, refinement of data collection tools (including paper-based standardized registers), and gradual capacity building before full-scale digital integration is attempted.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Key Structural and Data Barriers to NCD Management and VBC\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis table identifies critical structural and data-related barriers affecting the management of non-communicable diseases (NCDs) and the feasibility of value-based care (VBC). It includes metrics and statistics that illustrate the impact of these barriers on NCD care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBarrier Domain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMetric/Statistic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eImpact on NCD Care/VBC Feasibility\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSource\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eHealth Workforce Density\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e0.11 Clinicians per 1000 population\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eLimits specialist supervision, necessitates large-scale task shifting.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eService Fragmentation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026gt;80% Private Sector Delivery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eInconsistent quality, hinders standardization of VBC protocols.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eData System Reliability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e~50% DHIS2 facility reporting rate; \u0026gt;60% facilities lack reliable data.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eImpedes tracking of outcomes necessary for VBC payment models.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003ePrevention Funding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026lt;10% of Health Expenditure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eUndermines proactive investments essential for NCD prevention.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003ePatient Education/Literacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026gt;70% of diabetes patients lack adequate education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003ePoor self-management, limits utility of standard PROMs.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTo understand the challenges faced in managing Non-Communicable diseases, it is essential to identify key barriers. Table 2 highlights the structural and data-related barriers that impact NCD management and the implementation of value-based care.\u0026quot;\u003c/p\u003e"},{"header":"8. Synthesis and Policy Roadmap for Health System Transformation","content":"\u003ch3\u003e8.1. Comparative Analysis: Lessons from Regional NCD Strategies\u003c/h3\u003e\n\u003cp\u003eSuccessful NCD strategies in neighboring states provide essential evidence for Somalia\u0026apos;s roadmap. Both Kenya and Ethiopia have demonstrated significant progress by integrating NCD management into their Primary Health Care systems. These countries prioritized the development of comprehensive national NCD management frameworks, invested public resources into prevention, and scaled up community health initiatives.\u003c/p\u003e\n\u003cp\u003eThe primary lesson transferable to Somalia is the necessity of strong, coordinated policy that mandates integration. Where Somalia\u0026rsquo;s successful urban pilot programs remain isolated due to fragmentation, Kenya and Ethiopia established national mechanisms to replicate and fund these initiatives across different regions. This demonstrates that political will and institutional coordination are preconditions for scaling NCD management systems beyond localized projects.\u003c/p\u003e\n\u003ch3\u003e8.2. Strategic Policy Roadmap: Aligning NCD Control with HSSP III\u003c/h3\u003e\n\u003cp\u003eAchieving resilient NCD management requires a phased, long-term strategic roadmap aligned with the existing National Health Sector Strategic Plan (HSSP III 2022-2026).\u003c/p\u003e\n\u003ch4\u003e8.2.1. Phase I (1\u0026ndash;2 Years): Foundation and Pilots\u003c/h4\u003e\n\u003cp\u003eThe immediate priority must be establishing the foundational policy and operational requirements. This involves finalizing the National NCD Policy and integrating it officially into the HSSP III framework. Crucially, the Ministry of Health must standardize SOPs for NCD medicine management, quantification, and supply chain. Simultaneously, VBC pilot programs should be launched in select, regulated PHC centers, focusing on high-prevalence conditions (Hypertension/Diabetes) and utilizing adapted outcome measures (ObSROMs, clinical control targets).\u003c/p\u003e\n\u003ch4\u003e8.2.2. Phase II (3\u0026ndash;5 Years): Scaling and Integration\u003c/h4\u003e\n\u003cp\u003eOnce pilots demonstrate success, the focus shifts to broad system scaling. This includes the formal adoption and cascade training of the WHO HEARTS/PEN models to integrate NCD chronic care management into PHC across multiple regions. NCD monitoring and VBC performance metrics must be digitally integrated into the DHIS2 system as its functionality improves. Institutional capacity strengthening must establish transparent federal-state accountability frameworks with defined NCD outcome targets.\u003c/p\u003e\n\u003ch4\u003e8.2.3. Phase III (Long-Term): Financial Resilience\u003c/h4\u003e\n\u003cp\u003eThe long-term goal is financial sustainability and protection. This phase involves expanding the UHC index beyond the current 25% , developing sustainable public risk-pooling mechanisms, and institutionalizing VBC as the default reimbursement model. Success in this phase will significantly reduce catastrophic out-of-pocket expenditures for NCD patients.\u003c/p\u003e\n\u003ch3\u003e8.3. Detailed Implementation Strategies\u003c/h3\u003e\n\u003ch4\u003e8.3.1. Financial Model Revision\u003c/h4\u003e\n\u003cp\u003eThe transition from FFS to outcome-based contracts should begin with piloting \u003cstrong\u003ebundled payments\u003c/strong\u003e for chronic care packages (e.g., a defined annual budget covering routine monitoring, medication, and counseling for diabetes management). Providers would be rewarded for achieving target outcomes (e.g., keeping \\text{HbA}_{1\\text{c}} or blood pressure below defined thresholds) rather than the volume of services delivered. This provides a direct financial incentive for preventative measures and adherence support.\u003c/p\u003e\n\u003ch4\u003e8.3.2. Infrastructure Investment for Continuity\u003c/h4\u003e\n\u003cp\u003eTargeted capital investment is required to equip rural PHC centers specifically for NCD management. This includes securing essential NCD medication supplies (aligned with new SOPs) and technology for data collection (e.g., reliable blood pressure monitors, glucose meters) and patient management systems. Furthermore, investment must focus on establishing reliable, two-way standardized referral pathways to ensure continuity of care, preventing PHC patients from defaulting to expensive emergency care.\u003c/p\u003e\n\u003ch4\u003e8.3.3. Policy for Community Empowerment\u003c/h4\u003e\n\u003cp\u003eA robust strategy for enhancing health literacy is paramount. This requires the implementation of culturally sensitive, targeted educational campaigns delivered through expanded CHW networks. Crucially, specific policy interventions must address the complex behavioral risk factors, including coordinated policy and economic action (e.g., taxation, regulation) targeting Khat use to mitigate its documented association with hypertension and mental health decline.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3: Phased Roadmap for NCD Integration into Primary Healthcare (PHC)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis table outlines a strategic framework for integrating non-communicable diseases (NCDs) into primary healthcare systems. It details key interventions across four pillars: Financing Models, Workforce Capacity, Policy \u0026amp; Governance, and Data \u0026amp; Monitoring, with specific short-term (1-2 years) and long-term (3-5 years) goals for each intervention.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"650\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePillar of Transformation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntervention Type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eShort-Term Goals (1-2 Years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLong-Term Goals (3-5 Years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFinancing Models\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eVBC Transition/OOP Reduction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003eImplement VBC pilot programs focused on BP/Glucose control in PHC centers; Finalize National NCD SOPs/drug quantification.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003eDevelop public risk-pooling mechanisms; Reduce reliance on catastrophic OOP expenditure.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWorkforce Capacity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eTask-Shifting/Training\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003ePilot WHO HEARTS/PEN cascade training for CHWs and nurses. Conduct immediate needs assessment for chronic care specialists.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003eIntegrate chronic care management and preventive education into national medical curricula ; Achieve WHO minimum specialist density in PHC catchment areas.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePolicy \u0026amp; Governance\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eRegulatory Frameworks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003eFinalize and adopt National NCD Policy; Establish transparent federal-state NCD target accountability.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003eFully fund and empower the NHPC to regulate private NCD services; Integrate NCD planning into HSSP framework reviews.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eData \u0026amp; Monitoring\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eHMIS/VBC Metrics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003eAdapt PROMs/ObSROMs for low-literacy context; Improve DHIS2 reporting rates to above 70% in pilot regions.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003eFully integrate NCD surveillance and VBC performance tracking into a resilient national DHIS2.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTo effectively manage non-communicable diseases, a phased roadmap has been developed (Table 3). This roadmap includes targeted interventions that address financing, workforce capacity, policy frameworks, and data monitoring.\u0026quot;\u003c/p\u003e"},{"header":"9. Consequences of Systemic Failures: Patient and Societal Impact","content":"\u003cp\u003eThe failure to restructure the healthcare system to meet the demands of the NCD epidemic carries severe consequences at both the individual (micro) and national (macro) levels.\u003c/p\u003e\n\u003ch3\u003e9.1. Micro-Level Impact: Patient Care and Quality of Life\u003c/h3\u003e\n\u003ch4\u003e9.1.1. Health Literacy Gap\u003c/h4\u003e\n\u003cp\u003eThe current systemic failure results in a profound health literacy gap among NCD patients. Data indicates that over 70% of individuals diagnosed with diabetes in urban settings have not received adequate education on managing their condition. This lack of self-management education is the direct antecedent to poor clinical outcomes, leading to increased rates of preventable complications such as cardiovascular disease, kidney failure, and amputations. Without continuous education, medication adherence falters, undermining any clinical intervention provided.\u003c/p\u003e\n\u003ch4\u003e9.1.2. Psychological and Emotional Toll\u003c/h4\u003e\n\u003cp\u003eChronic illness places a significant psychological and emotional burden on patients and their families, particularly in a context of limited support and extreme financial strain. The inability to manage a long-term condition effectively in a reactive health system leads to chronic feelings of helplessness and frustration. This emotional distress contributes to mental health issues like anxiety and depression, which are frequently neglected in NCD care but are intrinsically linked to poor adherence and management (especially when exacerbated by risk factors like Khat use). Systemic failures in NCD care extend beyond physical morbidity to compromise overall well-being and mental health stability.\u003c/p\u003e\n\u003ch3\u003e9.2. Macro-Level Impact: Economic and Developmental Constraints\u003c/h3\u003e\n\u003ch4\u003e9.2.1. Lost Productivity and Human Capital Erosion\u003c/h4\u003e\n\u003cp\u003eAt the macro-level, premature NCD mortality and morbidity severely diminish the productive workforce, resulting in the erosion of human capital. Chronic illness reduces worker availability and efficiency, directly hindering national development and poverty reduction efforts. The economic cost extends beyond direct healthcare expenditure, encompassing lost wages, reduced household income, and increased reliance on external aid, ultimately stalling economic recovery.\u003c/p\u003e\n\u003ch4\u003e9.2.2. Perpetuation of Health Inequities\u003c/h4\u003e\n\u003cp\u003eThe reliance on high Out-of-Pocket (OOP) payments and the fragmentation of care toward an unregulated private sector ensures that NCDs become a disease of poverty. The current system disproportionately affects the poor, who are least able to afford continuous care, medications, and the non-medical costs associated with chronic disease management. This reliance on user fees perpetuates health inequities, transforming NCDs from a health challenge into a fundamental driver of social and economic disparity. Without policy intervention that mitigates financial toxicity (such as VBC or risk pooling), the health system will continue to solidify and deepen existing social inequalities.\u003c/p\u003e"},{"header":"10. Conclusion and Strategic Recommendations","content":"\u003ch3\u003e10.1. Summary of Key Findings and Thematic Synthesis\u003c/h3\u003e\n\u003cp\u003eThe analysis confirms that Somalia’s health system stands at a critical juncture, facing a rapidly accelerating NCD burden (25-30% mortality share, 33% hypertension prevalence) that is structurally opposed by a health architecture optimized for acute care. The core conflict resides in the confluence of low public financing, high financial toxicity driven by FFS and catastrophic OOP payments, acute workforce scarcity (0.11 clinicians/1000) , and fragmented governance that prevents quality standardization and data collection.\u003c/p\u003e\n\u003cp\u003eTo achieve meaningful and sustainable improvements in health outcomes, the shift from a reactive, crisis-management approach to a proactive, long-term health management model is imperative. This transformation demands not only clinical interventions but fundamental structural, financial, and regulatory reforms that redefine how NCDs are perceived and managed in a fragile context.\u003c/p\u003e\n\u003ch3\u003e10.2. Expanded Strategic Recommendations (Policy Prescriptions)\u003c/h3\u003e\n\u003cp\u003eBased on the synthesis of systemic barriers and evidence from regional models, the following five strategic recommendations form the core of the Value-Based Policy Roadmap for NCD control in Somalia:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003e\u003cstrong\u003eRevise Reimbursement Models (Financial Restructuring):\u003c/strong\u003e The Federal Ministry of Health must mandate VBC pilot studies immediately, focusing on high-prevalence NCDs. The long-term policy goal is the institutionalization of outcome-based contracting (e.g., bundled payments for chronic care) to eliminate the volume incentive inherent in FFS and incentivize preventive care, thereby providing an essential layer of financial risk mitigation against catastrophic health expenditure.\u003c/li\u003e\n\u003c/ol\u003e\n\u003col start=\"2\"\u003e\n \u003cli\u003e\u003cstrong\u003eInvest in Integrated Primary Healthcare Infrastructure and Continuity:\u003c/strong\u003e Strategic capital investment must prioritize equipping rural PHC centers with the necessary resources (essential NCD medications, diagnostic tools) and the implementation of standardized NCD-specific SOPs for continuous service delivery. This must be coupled with the establishment of reliable, two-way referral pathways to ensure that PHC can effectively manage chronic conditions and prevent unnecessary escalations to acute hospital care.\u003c/li\u003e\n\u003c/ol\u003e\n\u003col start=\"3\"\u003e\n \u003cli\u003e\u003cstrong\u003eEmpower Communities and Address Unique Risk Factors:\u003c/strong\u003e A significant expansion of the Community Health Worker network is required, coupled with funding for culturally sensitive, outcome-driven health literacy programs. Policy must include coordinated multi-sectoral interventions specifically targeting Khat use, recognizing its unique role as a critical behavioral risk factor that drives hypertension and complicates mental health integration.\u003c/li\u003e\n\u003c/ol\u003e\n\u003col start=\"4\"\u003e\n \u003cli\u003e\u003cstrong\u003eStrengthen Political and Institutional Capacity (Governance):\u003c/strong\u003e The National NCD Policy must be finalized, adopted, and operationalized with clear implementation targets integrated into the HSSP III framework. Sustainable funding must be secured for regulatory bodies (e.g., NHPC) to enforce quality standards across the fragmented private sector. Furthermore, the establishment of transparent federal-state accountability frameworks tied to tangible NCD outcome targets is crucial to ensure equitable policy reach across the Federal Member States.\u003c/li\u003e\n\u003c/ol\u003e\n\u003col start=\"5\"\u003e\n \u003cli\u003e\u003cstrong\u003eTransform Health Workforce Education and Delivery:\u003c/strong\u003e The health system must formally adopt and implement the WHO PEN and HEARTS technical packages using cascade training models, leveraging task-shifting to integrate NCD chronic care management into PHC. National medical curricula must be comprehensively overhauled to emphasize chronic disease management, patient education, and preventive care strategies, addressing the fundamental training deficiencies identified in the current workforce.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e The authors declare that no external funding was received for the development of this manuscript or the literature synthesis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Considerations:\u003c/strong\u003e This study is based on a comprehensive review and synthesis of publicly available and grey literature. The study complies with ethical standards for research review and analysis, and no ethical approval was required as no human subjects, confidential patient data, or primary interventions were involved.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest:\u003c/strong\u003e The authors declare no conflicts of interest related to the subject matter, the analysis conducted, or the conclusions presented in this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ Contributions:\u003c/strong\u003e All authors contributed substantially to the conception of the manuscript structure, the systematic review methodology, the synthesis of data, and the drafting and critical revision of the final policy report.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e The authors acknowledge the crucial work of public health agencies, international partners (WHO, Global Fund), and local government bodies whose reports and data provided the empirical foundation for this system analysis and policy roadmap.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAfrican Health Observatory. (2022). \u003cem\u003eHealth Expenditure in Somalia\u003c/em\u003e.\u003c/li\u003e\n \u003cli\u003eGlobal Burden of Disease Collaborative Network. (2024). \u003cem\u003eGlobal Burden of Disease Study 2021 (GBD 2021) Results\u003c/em\u003e.\u003c/li\u003e\n \u003cli\u003eGlobal Fund. (2021). \u003cem\u003eHealth System Assessment in Somalia\u003c/em\u003e.\u003c/li\u003e\n \u003cli\u003eKenya Health Information System. (2021). \u003cem\u003eImpact of Value-Based Care Models\u003c/em\u003e.\u003c/li\u003e\n \u003cli\u003eMarmot M, et al. (2019). \u003cem\u003eThe Health Gap: The Challenge of an Unequal World\u003c/em\u003e.\u003c/li\u003e\n \u003cli\u003eSomali Ministry of Health. (2022). \u003cem\u003eNational Health Strategy Report\u003c/em\u003e.\u003c/li\u003e\n \u003cli\u003eSomali Health and Demographic Survey. (2020).\u003c/li\u003e\n \u003cli\u003eWHO. (2021). \u003cem\u003eHealth Systems in Africa: Challenges and Opportunities\u003c/em\u003e.\u003c/li\u003e\n \u003cli\u003eWorld Health Organization. (2021). \u003cem\u003eShare of deaths by broad cause. Somalia\u003c/em\u003e.\u003c/li\u003e\n \u003cli\u003eWorld Health Organization. (2021). \u003cem\u003eGlobal action plan for the prevention and control of noncommunicable diseases 2013\u0026ndash;2030\u003c/em\u003e.\u003c/li\u003e\n \u003cli\u003eWorld Health Organization. (2021). \u003cem\u003eWHO package of essential noncommunicable (PEN) disease interventions for primary health care\u003c/em\u003e.\u003c/li\u003e\n \u003cli\u003eAbdi AM, Osman HM, Muhumed M. \u003cem\u003eThe Challenges of Somalia\u0026apos;s Healthcare System in Addressing Non-Communicable Diseases: Understanding the Complex Solutions Needed\u003c/em\u003e (Original Manuscript).\u003c/li\u003e\n \u003cli\u003eAbdirasak Mohamed A, et al. (2025). \u003cem\u003eChallenges and Opportunities in Utilizing Secondary Data for Health Research in Somalia: A Focus on Health Management Information Systems (HMIS)\u003c/em\u003e.\u003c/li\u003e\n \u003cli\u003eUNICEF/HISP-UIO. \u003cem\u003eDHIS2 in Somalia Partnership\u003c/em\u003e.\u003c/li\u003e\n \u003cli\u003eWorld Bank. (2021). \u003cem\u003eSomalia: Improving Healthcare Services in Somalia (Damal Caafimaad Project)\u003c/em\u003e.\u003c/li\u003e\n \u003cli\u003ePage MJ, et al. (2020). \u003cem\u003eThe PRISMA 2020 statement: an updated guideline for reporting systematic reviews\u003c/em\u003e.\u003c/li\u003e\n \u003cli\u003eMoher D, et al. (2009). \u003cem\u003ePreferred Reporting Items for Systematic reviews and Meta-Analyses: The PRISMA Statement\u003c/em\u003e.\u003c/li\u003e\n \u003cli\u003eWorld Health Organization. (2021). \u003cem\u003eWHO\u0026rsquo;s work on noncommunicable diseases\u003c/em\u003e.\u003c/li\u003e\n \u003cli\u003eGBD 2021 DALY Collaborators. (2024). \u003cem\u003eGlobal incidence, prevalence, years lived with disability (YLDs), disability-adjusted life-years (DALYs)\u003c/em\u003e.\u003c/li\u003e\n \u003cli\u003eKruk ME, et al. (2022). \u003cem\u003eThe financial burden of noncommunicable diseases in sub-Saharan Africa: a systematic analysis\u003c/em\u003e.\u003c/li\u003e\n \u003cli\u003eUNDP Somalia. (2023). \u003cem\u003eNational Transformation Plan (NTP) 2025\u0026ndash;2029 Roundtable\u003c/em\u003e.\u003c/li\u003e\n \u003cli\u003eSDC-funded PSPH Program. (2024). \u003cem\u003ePrivate Sector Partnerships in Health: Mobilizing private healthcare providers in forming unions\u003c/em\u003e.\u003c/li\u003e\n \u003cli\u003eGHDX. (2021). \u003cem\u003eDeath rate from cardiovascular diseases in Somalia\u003c/em\u003e.\u003c/li\u003e\n \u003cli\u003eAl Khalili R. (2024). \u003cem\u003eSomaliland\u0026rsquo;s Khat Conundrum\u003c/em\u003e.\u003c/li\u003e\n \u003cli\u003eAbate T, et al. (2021). \u003cem\u003ePrevalence and factors associated with Khat chewing among the general population\u003c/em\u003e.\u003c/li\u003e\n \u003cli\u003eSomalia Federal Government. (2022). \u003cem\u003eNational Health Sector Strategic Plan 2022-2026 (HSSP III)\u003c/em\u003e.\u003c/li\u003e\n \u003cli\u003eWorld Diabetes Foundation. (2023). \u003cem\u003eSupporting the development of standard operating procedures for NCD medicines and technologies in Somalia\u003c/em\u003e.\u003c/li\u003e\n \u003cli\u003eWHO. (2022). \u003cem\u003eWHO HEARTS technical package\u003c/em\u003e.\u003c/li\u003e\n \u003cli\u003eUNICEF Somalia. (2020). \u003cem\u003eHarmonised Community Health Workers Training Manual\u003c/em\u003e.\u003c/li\u003e\n \u003cli\u003eGBD 2021 Mortality Collaborators. (2024). \u003cem\u003eEstimates of global mortality and years of life lost due to COVID-19\u003c/em\u003e.\u003c/li\u003e\n \u003cli\u003eNaimoli J, et al. (2022). \u003cem\u003eTask shifting for non-communicable disease management in conflict-affected settings\u003c/em\u003e.\u003c/li\u003e\n \u003cli\u003eWorld Bank. (2022). \u003cem\u003eSomalia: Current health expenditure per capita\u003c/em\u003e.\u003c/li\u003e\n \u003cli\u003eGRADE Working Group. (2004). \u003cem\u003eGrading quality of evidence and strength of recommendations\u003c/em\u003e.\u003c/li\u003e\n \u003cli\u003eWitter S, et al. (2022). \u003cem\u003eImplementation of Value-Based Health Care in low-resource settings\u003c/em\u003e.\u003c/li\u003e\n \u003cli\u003eGhana VBC Investigators. (2024). \u003cem\u003eValue-Based Care intervention for poorly controlled hypertension in Ghana\u003c/em\u003e.\u003c/li\u003e\n \u003cli\u003evan der Merwe L, et al. (2020). \u003cem\u003eMeasuring health outcomes in Africa: Patient-reported outcome measures (PROMs) protocol\u003c/em\u003e.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Benadir University","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Non-Communicable Diseases, health system challenges, Somalia, Value-Based Care, healthcare policy, Sustainable Development Goals, Khat, Fragile States","lastPublishedDoi":"10.21203/rs.3.rs-7925625/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7925625/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eNon-Communicable Diseases (NCDs), encompassing conditions such as hypertension, diabetes, and cancers, have rapidly transitioned from a secondary concern to a significant public health threat in Somalia. This epidemiological shift necessitates urgent examination of the healthcare system\u0026rsquo;s fundamental capacity to address chronic conditions. NCDs currently account for an estimated 25% to 30% of all fatalities, highlighting the severe disconnect between the traditional acute-care focus of the Somali health system and the requirements of long-term chronic disease management. This report analyzes the systemic barriers inhibiting effective NCD control and proposes a Value-Based Care (VBC) centered policy roadmap for sustainable health system transformation.\u003c/p\u003e\u003ch2\u003eMethodology:\u003c/h2\u003e\u003cp\u003eA systematic policy synthesis was conducted, aligning with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) framework. The analysis included a comprehensive review of peer-reviewed literature indexed in databases such as PubMed, Scopus, and Google Scholar, alongside grey literature from the World Health Organization (WHO), the Global Burden of Disease (GBD) project, and official Somali Ministry of Health reports published within the last decade. Data were thematically synthesized using the WHO Health Systems Building Blocks as the \u003cem\u003ea priori\u003c/em\u003e analytical framework, and policy recommendations were graded using established criteria to assess the certainty of evidence.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eKey findings confirm a severe NCD burden (e.g., hypertension affecting approximately 33% and diabetes affecting 20% of the adult population). Systemic challenges are categorized under four pillars: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) Governance, characterized by service fragmentation and a weak regulatory environment; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Financing, dominated by a fee-for-service model and resulting in high catastrophic health expenditure (CHE) for NCD households; (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) Workforce, facing an acute scarcity (0.11 clinicians per 1,000 population) and training misalignment; and (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) Information, plagued by low reporting rates in the DHIS2 system (around 50%). A crucial finding is the unique role of Khat chewing as a major behavioral and policy target driving hypertension and complicating mental health integration.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eSomalia faces a multi-faceted crisis requiring a comprehensive, multi-sectoral response. The adoption of a phased VBC roadmap, focusing on financial model revision, task-shifting integration (WHO PEN/HEARTS), and rigorous, adapted outcome measurement (PROMs/ObSROMs), is essential. Strategic policy alignment, including finalizing the National NCD Policy and strengthening federal-state accountability, is necessary to transition the health system from a reactive model to one capable of achieving global targets for NCD control (SDG 3.4).\u003c/p\u003e","manuscriptTitle":"The Unrecognized Challenge: A Value-Based Policy Approach to Combat Non-Communicable Diseases in Somalia's Health Sector","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-24 06:58:55","doi":"10.21203/rs.3.rs-7925625/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 24th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":56726155,"name":"Health Economics \u0026 Outcomes Research"},{"id":56726156,"name":"Health Policy"},{"id":56726157,"name":"Health Law"}],"tags":[],"updatedAt":"2025-10-24T06:58:55+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-24 06:58:55","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7925625","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7925625","identity":"rs-7925625","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}