3.3. Summary of Findings
3.3.1. Health
Availability, accessibility, and coverage of Antenatal Care (ANC) were the most reported health outcomes, recorded in 15 (38.4%) of 39 articles. In contrast, immunisation coverage followed, as reported in 13 (33.3%) of the 39 studies.
1) Availability, Accessibility and Coverage of ANC
This review found that the number of women attending ANC, even for their first visit, is low in Somalia. From the global perspective, the lowest ANC attendance was 9.4% from Somalia, as reported by a study using the Global Health Observatory of WHO ([60]). Similarly to this, the 2020 Somalia Demographic and Health Survey (SHDS) reported that 68% of women did not attend any ANC visits during pregnancy ([48]). Three regional studies conducted in Somaliland, Southern and Central Somalia reported incomplete attendance at ANC visits, as most women attended only the first two visits. Thereafter, a significant dropout rate of almost 50% occurred in all three studies, leading to fewer women completing all four or more ANC visits ([39]; [44]; [60]). Notably, one study reported that most mothers (62.3% of 330) initiated ANC in the second trimester of pregnancy, contrary to the recommended 1st trimester ([44]).
Lack of knowledge on the importance and regularity of ANC visits was reported as a barrier in two studies ([39]; [44]). Long distance to facilities ([39]) and long waiting hours ([44]) were also reported as barriers. Possible recommendations in averting these barriers include increasing awareness among pregnant women and their husbands for a comprehensive support system ([39]).
The included studies did not report on strategies employed to enhance availability, accessibility and coverage of MCH.
2) Availability, Accessibility and Acceptability of Contraception Methods
Six of the studies on health reported on contraception, including post-abortion care. Contraception use in Somalia is critically low at less than 10%, with 90.9% of its female population having no intention to use contraception, as reported in three articles ([22]; [34]; [48]). Nationwide, modern contraception was used by only 0.9% of the population, with 6.1% preferring traditional methods, specifically, the rhythm method ([34]; [48]). The use of pills was selected by 0.4% of the population, with 0.2% using implants, 0.1% using Intrauterine Device (IUD) and Lactational Amenorrhea Method (LAM), and 0.03% using condoms ([34]). The recognised family planning products in the country, according to the 2008 Somali Birth Spacing Guideline, are ([4]):
1) Oral Hormonal Contraceptives
a) Ethinylestradiol (30 µg) + levonorgestrel (150 µg)
b) Ethinylestradiol (35 µg) + norethisterone (1 mg)
2) Injectables
a) Medroxyprogesterone acetate IM/SC injection
b) Estradiol cypionate + medroxyprogesterone acetate (5 - 25 mg) injection
c) Norethisterone enantate: 200 mg/mL in 1 mL ampoule
3) Implants
a) Levonorgestrel-releasing implant (150 mg)
b) Etonogestrel-releasing implant (68 mg)
4) IUDs
a) Copper-containing IUD
b) Levonorgestrel-releasing IUD
5) Emergency Contraceptives
a) Ulipristal tablet (30 mg)
b) Levonorgestrel (30 µg or 750 µg [pack of two]; 1.5 mg)
Multiple barriers to contraception use were identified. At the individual level, Knowledge of the availability, mode of action and benefits of contraception use was low at about 12.8% of the national population ([22]). Additionally, fear and misconceptions about the effects of contraception were also identified ([34]). Social constraints included the value of large families, male dominance in decision-making or lack of engagement altogether and other competing problems such as poverty and hunger ([11]; [34]; [40]). Contraception uptake was particularly challenging to pastoral communities within the Mudung region that faced challenges such as long distances to the health facilities, cost constraints and supply shortages affecting the availability and accessibility of contraceptives ([16]). A critical barrier was the reported absence of recent national family planning policies as well as weak referral pathways; the present guideline currently in use is the 2008 Somali Birth Spacing Guidelines ([4]; [34]; [40]).
Recommendations for enhancing this uptake included the immediate integration of contraceptive education and sensitisation activities for women and men of all ages. This should go hand in hand with prioritising the availability of quality sexual and reproductive health counselling and products in all health facilities, including pastoral regions and Internally Displaced Persons (IDPs) camps ([22]; [34]). There is a need for regulatory oversight to facilitate the introduction of contraceptives in the formal markets, considering the willingness of pharmacists to stock and sell the contraception when made available in the market ([26]). Lastly, the development of evidence-based policies is critical in advocacy for the availability of these contraceptives from the clinical point of view ([4]).
3) Post Abortion Care (PAC)
Abortion is a sensitive topic due to religious and social conservatism in Somalia, and due to this, the acceptability and availability of the services are low. According to the 2008 Somali Birth Spacing Guidelines, the medical termination drugs available in the country are Misoprostol (either 400 µg or 600 µg, PO) and Misoprostol and mifepristonecombipack ([4]).
A key strategy to promote the uptake of PAC, as reported in two regional studies, was the use of a multi-pronged PAC program (2012-2017) comprising capacity-building activities for women, a steady supply of services, products, and infrastructure, community collaboration and mobilisation, and, lastly, regular monitoring and evaluation ([11]; [21]). This strategy significantly increased the number of PAC clients, rising from 11 in 2012 to 1065 in 2017. Additionally, the percentage of PAC clients choosing contraception increased from 64%, and the use of Long-Acting Reversible Contraceptives (LARCs) rose from 14% in 2012 to 24% in 2017 ([21]). Narrowing down to a study in Puntland (2013-2015), the same strategy saw a high PAC acceptance rate, which was observed as 98% (1090/1111) of PAC clients were counselled for post abortion contraception, of which 88% (955) accepted a contraceptive method before leaving the facility ([11]). During this period, the monthly average of women receiving PAC increased from 19.91% (2013) to 34.75% (2014) and 37.92% (2015) (p < 0.01). 57% received Manual Vacuum Aspiration (MVA), 24% received misoprostol, and 19% underwent natural expulsion. The monthly mean number of PAC clients treated with misoprostol more than tripled from 3.17 (SD = 4.20) in 2013 to 11.5 (SD = 3.21) in 2015 (p < 0.001) ([11]).
The main barrier to this strategy was that Somalia is a religiously and socially conservative country with highly restrictive abortion laws, limiting them to life-threatening situations only ([11]). The project reported low involvement among men, citing it as a “woman’s issue”; neither did it target youth. This could potentially be addressed by tailored messages for the diverse community awareness activities to engage and mobilise men and youth more effectively ([11]). Lastly, the weakened health system, damaged by protracted crises, challenges the integration of care activities into the healthcare facilities ([11]).
The positive outcome of this strategic approach highlighted the need for increased investment in expanding quality PAC in crisis-affected areas, since the quality and availability remain insufficient in Somalia ([21]).
4) Child Immunisation Coverage
This review identified that the national immunisation coverage among children below 5 years in Somalia is critically low, decreasing with each required immunisation visit. Approximately 65.2% of the nation’s under-5 population was unvaccinated ([38]). Regionally, in the Mudug Galkayo region, only 20% of 357 children were fully vaccinated ([29]). In Mogadishu, 90.3% of 93 hospitalised children with measles had not previously received at least one dose of measles-containing vaccine (MCV1). On the contrary, Mogadishu had a higher vaccination coverage, with 74% of caregivers self-reporting that they were up to date with their child’s immunisation, leading to only 26% having missed vaccine recommendations ([43]). In response to concerns about vaccine coverage, the UNICEF Country Office’s Annual Report for 2023 reported that 17.7 million polio vaccine doses were available in Somalia. In 2023, 3.8 million children under five were vaccinated, and 91% of health facilities offered immunisation services equipped with solar-powered vaccine fridges ([57]).
This low vaccine coverage was attributed to multiple cross-cutting barriers. From an individual perspective, the lack of knowledge, low education, religious beliefs and misinformation among caregivers resulting from the absence of population-specific strategies and meaningful community engagement initiatives was a key barrier reported across five studies ([2]; [10]; [14]; [27]; [43]). Among marginalised groups such as pastoralists, long distances to health facilities and financial costs were noted as barriers among pastoralist communities ([10]).
From a health system perspective, insufficient supplies and equipment hindered vaccination through facility-related stock-outs and a lack of on-site cold chain storage facilities ([10]; [43]). Additionally, there was a notable challenge in surveillance, monitoring and evaluation due to the absence of accurate demographic data, outbreak investigation, civil registration systems, and reliable population estimates ([10]; [27]; [32]). Lastly, resource constraints and a heavy reliance on donor funding, coupled with a lack of transparency and misappropriation of funds, hinder immunisation efforts ([10]; [25]; [27]).
Recommendations to enhance vaccine coverage included the urgent prioritisation of targeted, context-specific awareness campaigns to strengthen caregiver awareness, focusing on vulnerable groups, poor households, pastoralists, IDPs and low-education caregivers ([2]; [10]; [38]; [41]; [43]). This can be achieved through trusted community Influencers in community engagement and advocacy, as well as local media engagement ([10]; [32]).
As for the pastoralists, seasonal migration patterns are known to local stakeholders, enabling targeted cyclic interventions based on the routes they take ([10]). With this, the use of mobile vaccine clinics and community health workers would enhance the coverage in remote areas or among pastoralist communities ([10]; [43]). Lastly, enhancing health systems through ensuring vaccine supplies, clear schedules, and staff training, alongside vaccination surveillance, monitoring, and record-keeping and contact tracing activities, was cited in 3 studies ([10]; [42]). The included studies did not report on strategies employed to enhance availability, accessibility and coverage of vaccines.
5) Mortality Rates among Children under 5
Eleven studies reported mortality rates among children under 5, most indicating a high mortality rate. According to the WHO’s 2017 country Cooperation Strategy for Somalia, the neonatal mortality rate was significantly high at 39.7 per 1000 live births [19.7 - 81.6], like the Under-five mortality rate at 136.8 per 1000 [80.2 - 242.4] ([59]). The neonatal and post-neonatal mortality rate from tetanus was also significantly high at more than 1000 deaths per 100,000 population and above five deaths per 100,000 population, respectively ([35]). The Global Burden of Disease Study of 2016 ranked Somalia among the countries with the highest under-5 mortality rates caused by lower respiratory infections (417 per 100,000 people, [95% UI: 257 - 613]) ([55]).
Regionally, among 513 neonates in Mogadishu in 2023, the mortality rate was observed as 26.5% [95% CI: 22.6 - 30.2] ([14]). In 2024, IDP camps within Mogadishu reported the death rate among 3898 children < 5 years to have exceeded emergency thresholds (>2 deaths per 10,000 children per day), reaching a peak of seven deaths per 10000 children per day during periods of protracted displacement and emergency influx amid the 2017 drought and health emergency ([47]). A hospital-based study conducted in 2020 in Somaliland among 164 neonates reported a mortality rate of 16 per 1000 live births in the hospital ([36]).
A vital recommendation identified was to strengthen the ability of healthcare workers and health institutions to provide antenatal, postnatal and newborn care, which is crucial ([14]). The included studies did not report on strategies employed to curb mortality rates among children under 5 years of age.
6) Maternal Mortality Rates
Three articles reported maternal mortality rates, indicating that the rates are high but have gradually reduced over the past 10 years. Somalia’s maternal mortality rate dropped from 732 in 2015 to 692 maternal deaths per 100,000 live births in 2020 ([48]). One per 1000 women aged 15 - 49 died from pregnancy or birth-related complications IN 2020. The death rate is highest among women aged 30 - 34, at 10.9 deaths per 1000 population ([48]). WHO’s 2017 Country Cooperation Strategy recorded a Maternal mortality ratio of 732 per 100,000 [361 - 1390] ([59]). The second study notes that between 2006 and 2020, there was a 44% reduction in the MMR, from 1044 to 592 per 100,000 live births (p < 0.01) ([9]). The included studies did not report on strategies to curb maternal mortality rates.
7) Stunting Rates among Children under 5
Stunting rates remain moderately high in Somalia. The SDHS of 2020 reports that 27% of children are stunted, 16% are severely stunted and that stunting peaks at 21 months from birth (39%) ([48]). The use of unconditional cash transfer was reported in two articles as a possible strategy to mitigate these high rates of stunting. The first one found no significant improvements in nutrition indicators, including stunting ([7]). This was attributed to poor socioeconomic and feeding practices among the target beneficiaries and an extreme drought that hindered food production. It recommends that future cash transfer projects should consider providing proper training and supervision to the caregivers, the amount of cash given, and the other health and nutrition services provided to the children and caregivers to achieve a holistic effect ([7]).
3.3.2. Water, Sanitation and Hygiene
This review identified that the WASH situation in Somalia is greatly challenged. Four articles, including the UNICEF’s 2023 Country Office Annual Report and the SDHS of 2020, reported that approximately 50% of the country’s population lacked access to improved drinking water ([5]; [28]; [38]; [48]; [57]). Additionally, 50% of the population faced sustainable and safe drinking water shortages in 2023 ([57]). Regionally, out of 167 households in the Jariban district in Somalia, only 57.5% had access to safe drinking water sources ([37]). Additionally, 42.5% of respondents did not have access to safe drinking water sources, and only 10.8% confirmed that they treat drinking water at the point of use ([37]). However, one study reported critically low availability of improved drinking water sources (22.04% (95% CI: 21.5%, 22.4%)) among 32,300 participants from the Awdal, WaqooyiGalbeed, Togdheer, Sool, Sanaag, Bari, Nugaal, Mudug, Galgadud, Hiran, MiddleShabelle, Banadir, Bay, Bakool, and Gedo regions ([38]).
The Sanitation situation in the country is also reportedly weak. According to UNICEF’s surveillance in 2023, only 33% of the national population used safely managed sanitation services ([57]). Additionally, the SDHS reports that more than half of the national population uses unimproved latrines: 6499 (41.1%) ([48]). In the Jariban district of Somalia, it was reported that only 26.9% of 167 households had access to basic sanitation. Of the respondents, 44.3% shared latrines, resulting in open defecation.
Looking at strategies to enhance WASH in Somalia, one study conducted between October 2021 and March 2022 in the Kahda district reported the use of the SurpriseSoapintervention, where soap with embedded toys was delivered through a short household session comprising a glitter game, instructions on how and when to wash hands, and Handwashing with Soap (HWWS) practice ([58]). There was an increase in HWWS in both the intervention group (+48 percentage points) and the control group (+51 percentage points) after baseline, and this increase remained stable over the 16-week follow-up period. Additionally, the presence of Handwashing stations increased from 81% to 96% (intervention) and 93% (control) ([58]).
Key barriers to adequate WASH coverage were limited involvement and coordination of diverse stakeholders and poor water quality, citing high chemical content and salinity ([15]; [30]).
As noted in one study, mutual accountability to strengthen national WASH systems was identified as a potential opportunity to achieve SGD-related WASH outcomes ([15]). However, it said that there were limited WASH Multi-Stakeholder Platforms (MSPs) due to the post-civil war recovery, with only two existing coordination mechanisms: the Inter-ministerial WASH Steering Committee, which focuses on government coordination, and the WASH Humanitarian Response Coordination Forum, which focuses on emergency response. This was attributed to barriers such as limited involvement of diverse stakeholders and a greater focus on humanitarian coordination than long-term WASH development ([15]).
3.3.3. Social Protection
The most common strategy used for social protection was reported as an unconditional cash transfer and food and water aid, more so among IDPs, to enhance food security and livelihoods ([18]; [20]; [24]). One study reported the use of food and water aid from NGOs to IDPs in averting drought and promoting social development in Badbaado Camp and Raja Camp ([1]). This study found a positive effect, indicating that food and water supplies from NGOs aid in recovery from Droughts (mean answers = 2.60 and 2.99, respectively, with high agreement in both cases) (p-value < 0.005). However, two studies, conducted in Dayniile and Dharkanley and Mogadishu, reported no significant effect of unconditional cash transfers on food intake, food quantity or nutrition indicators, including stunting, wasting and underweight (OR: 0.78; 95% CI: 0.65 - 0.92) ([7]; [20]), with one reporting an increase in household conflict (OR: 2.90; 95% CI: 1.29 - 6.48) ([20]).
Some of the main barriers reported included poor socioeconomic and feeding practices among the target beneficiaries, extreme drought hindering food production and the lack of individualised and adapted nutrition counselling for each mother-child pair ([7]; [25]).
One crucial recommendation to achieve significant effects was the provision of cash transfers alongside nutrition education and training, also known as Cash-Plus ([24]). Secondly, attention should be given to assess unique contexts for deviations from average household size and population composition to ensure voucher entitlements are appropriate and aligned to community and household needs ([20]; [24]).
3.3.4. Gender Equity
Three articles reported on gender equity, highlighting the marginalisation of females, especially girls; however, various strategies have made positive progress toward achieving this. Only one article reported that the gender parity index in Somalia had risen from 0.80 (2022) to 0.84 (2023) ([57]). In Puntland and Somaliland in 2019, one study highlights that child marriage has become more common over the past decade, with the average age of marriage dropping to 14 ([33]). While traditional arranged marriages still exist, elopement is becoming more frequent among adolescents ([33]). It also notes that education is highly valued, with parents expressing a strong desire for their children to complete their education before marriage. However, some parents accept early marriage due to societal pressures and norms ([33]). Unlike in the past, when parents arranged marriages, adolescents now make their own choices, often without parental consent. Social media and smartphones facilitate relationships, leading to spontaneous elopements ([33]).
In leadership, women’s participation in local government politics has contributed to economic growth and development in Warta-Nabada District, Banadir, by prioritising their access to education, healthcare, employment recommendations, and socio-political rights ([3]).
One strategy to enhance gender equity is the Communities Care Programme (CCP), which facilitates dialogues with community members to catalyse Gender Based Violence (GBV) prevention actions and provides training to diverse sectors to strengthen response services for GBV survivors ([23]). The strategy targeted social norm transformation and gender relations instead of the usual behaviour change through knowledge and awareness ([33]). This intervention was applied to 192 households in Mogadishu, resulting in a significant improvement in response to sexual violence (b = −0.214, p = 0.041, ES = 0.28), a significant decline in the husbands right to use violence (b = −0.309, p = 0.003, ES = 0.38) and an increased confidence in GBV service provision (b = 0.318, p < 0.001, ES = 0.67) ([23]). The main challenges faced included peer pressure resulting in early marriages, financial constraints leading to early marriages and the negative influence of technology enhancing elopement ([23]; [33]).
3.3.5. Education
According to nationwide statistical analysis, educational levels in Somalia are low; 47% of females and 44% of males have never attended school ([48]). Twelve percent have some primary education, but only three percent have completed it. Five percent attended secondary education, with only three percent completing it. Only 3% have completed higher education. By gender, 31% of females and 27% of males have some primary education. Younger males (20 - 24 years old) and females (15 - 19 years old) have the lowest rates of no education (21% and 23%, respectively) ([48]). UNICEF reported similar findings: in 2023, 4.8 million children (ages 5 - 17) were out of school, one of the highest rates globally. Additionally, school attendance was at 21% for newly displaced children and 39% for non-displaced children ([57]).
The Somalia Education for Human Capital Development Project by the Global Partnership for Education, which aims at promoting equity in education for the most socially excluded children, saw 2650 students (49% girls) from marginalised and IDP communities receive school fee support via direct transfers to parents ([49]). The project identified an urgent need for more professional development, better learning materials, and structured in-service training. It recommended addressing barriers to girls’ education and expanding scholarship programs, and improving school infrastructure planning and data management to increase access to primary education ([49]).
Secondly, the use of the Alternative Basic Education (ABE) programme was used to improve educational outcomes for pastoralist children and internally displaced children from 2016 to 2020 ([56]). These educational facilities provided children with a place to learn in their mother tongue and to participate in recreational activities, thus yielding positive literacy results ([56]). The ABE programme supports girls through interventions focusing on menstrual hygiene and gender-sensitive water, sanitation, and hygiene facilities. In hard-to-reach and high-risk locations, UNICEF-supported training and cash incentives help ABE centres to retain their teachers ([56]). The national primary gross enrolment rate increased from 31% (2022) to 37% ([57]). Additionally, 20,248 children (8707 girls) from nomadic pastoralist and IDP groups enrolled in education for the first time. In 2020, 937 students (403 girls) graduated from the four-year Accelerated Basic Education (ABE) cycle, becoming eligible for secondary school. The included studies did not explicitly address matters related to ECD or TVET education strategies.
3.3.6. Innovation
Only three studies reported on innovation matters. Studies conducted in Mogadishu reported the use of digital health strategies such as Electronic Health Records (EHRs) ([17]; [31]). As of 2024, among 35 diverse healthcare facilities in Somalia, 63% had adopted EHR systems with reported benefits, including improved accuracy of patient records, enhanced efficiency in clinical workflows, and better coordination of care. However, barriers such as technical issues, financial constraints, and a lack of technical expertise were cited ([17]). Digital health technologies in Mogadishu positively influenced healthcare workers’ performance (Î2 = 0.473, p < 0.001), significantly reduced healthcare workers’ workload (Î2=0.241, p < 0.001) and led to performance improvements (Î2 = 0.765, p < 0.001) by streamlining tasks ([31]).
However, in business, the innovation sector faces significant challenges in Mogadishu, as the country lacks an innovation policy and a science and technology framework for small and medium-sized enterprises and entrepreneurship ([13]). This makes doing business difficult. Additionally, no ministry was responsible for facilitating and embracing science and technology in the industry and technical institutions ([13]). It was recommended that science and technology be included in the national agenda to develop policy instruments addressing taxation and high electricity tariffs, as well as weak interlinkages among institutions and government agencies ([13]).