The review, led by Nasra Salad Ahmed of Somali National University and the Climate and Environmental Research Institute in Mogadishu, together with colleagues at the Center for Natural Resources in Brazil, followed PRISMA-ScR guidelines to search Scopus and Web of Science for literature published between 2000 and 2026. From 183 records identified, 54 sources of evidence were included and organized around six thematic domains: malaria burden and environmental risk; community health worker and integrated community case management service delivery; health-system strengthening and governance in fragile settings; community engagement and care-seeking; digital health and surveillance; and cross-cutting workforce evidence. The authors deliberately framed their synthesis through a One Health lens, recognizing that human malaria transmission is shaped not only by clinical services but also by vector ecology, climate variability, livestock-associated livelihoods, and population movement.

Uganda emerges from the analysis as the regional reference point. The country has built successive malaria-control strategies around insecticide-treated nets, indoor residual spraying, diagnostic testing, effective antimalarial treatment, and, critically, a formalized cadre of Village Health Teams embedded within national and district health structures. These community health workers act as an interface between households and facilities, supporting early recognition of malaria symptoms, community-level diagnosis and treatment where authorized, health education, and referral of patients requiring higher-level care. In western Uganda, long-term implementation of integrated community case management achieved a reported 74 percent correct-care rate for malaria management, a figure the review attributes not simply to individual worker competence but to the surrounding architecture of training, supervision, reliable commodity supply, and functional referral pathways.

A particularly instructive element of the Ugandan experience is the “pull-system” logistics approach, which linked community-level workers directly to facility-based supply chains for rapid diagnostic tests and artemisinin-based combination therapies. This design ensured that village health workers could consistently access the commodities they needed rather than depending on irregular campaign-based distributions. The review’s authors emphasize that this finding challenges a common assumption in global health: that expanding community health worker programs is primarily a matter of recruitment and short-term training. Instead, sustained impact depends on sustainable financing, standardized supervision, reliable commodity availability, facility linkages, monitoring, and accountability structures that connect community-level action to national health planning.

Somalia presents a starkly different operating environment. Decades of conflict, displacement, fragmented financing, and dependence on external partners have left the health sector structurally fragmented, with substantial geographic variation in service availability. WHO evidence cited in the review shows a complex epidemiological picture: reported malaria prevalence in the most affected areas declined from 20.1 percent in 2015 to 4.1 percent in 2023, yet malaria incidence rose from 3.4 percent in 2022 to 4.0 percent in 2023. These trends suggest that interventions can achieve real gains but that continuity and surveillance remain fragile. Children under five, pregnant women, rural and remote communities, pastoral populations, and internally displaced people face the greatest barriers to timely diagnosis, treatment, prevention, and referral.

The review identifies a critical evidence gap: unlike Uganda, where the literature provides detailed data on Village Health Team implementation, treatment-seeking behavior, quality of care, and health-system linkages, Somali studies rarely report nationally comparable indicators of community health worker density, supervision frequency, diagnostic availability, treatment coverage, or referral completion. The authors are careful to note that this scarcity of standardized data should not be interpreted as evidence that community-based delivery is ineffective in Somalia. Rather, it reflects weaknesses in routine implementation data and underscores the need to strengthen monitoring alongside service expansion. Priority indicators they propose include the geographic distribution of trained workers, population served per worker, supervision rates, commodity stock-outs, the proportion of suspected cases tested, and referral completion.

The One Health framework gives the review its distinctive analytical edge. Although livestock are not a biological reservoir for human malaria, Somalia’s predominantly pastoral and agro-pastoral livelihoods create human-animal-environment interfaces that shape mobility, settlement patterns, and healthcare access. Recurrent droughts and floods simultaneously affect livelihoods, displacement, water access, and service continuity, meaning climate variability interacts with existing health-system weaknesses rather than acting as an isolated determinant. The authors propose linking routine malaria surveillance with climate and rainfall data, vector surveillance, population displacement information, and community-level reporting. Remotely sensed rainfall, temperature, flooding, and vegetation data could be combined with community-reported cases to identify areas of rising transmission risk before outbreaks peak, enabling earlier deployment of vector control, diagnostics, and antimalarial supplies.

Digital health features prominently in the proposed pathway, but the review is deliberately cautious. Experiences from fragile and conflict-affected settings show that digital interventions succeed only when embedded within functional health systems with clear governance, trained users, reliable infrastructure, and mechanisms for translating data into action. In Somalia, where electricity and connectivity are unreliable, the authors recommend offline functionality, low-bandwidth operation, simple interfaces, and interoperability with existing health information systems. Mobile or offline-enabled reporting by community health workers could support timely notification of suspected case increases, outbreak investigation, and commodity allocation, while a nationally coordinated malaria dashboard could bring together indicators on cases, stock levels, coverage, and program performance to improve accountability across government, humanitarian, and donor actors.

The review also confronts the informal health sector. Community drug shops and private medicine vendors are often the most accessible and resilient points of care in communities affected by conflict, and patients do not bypass public facilities out of preference but because informal providers fill gaps left by distant or intermittently functional facilities. Unregulated distribution carries risks of inappropriate treatment, delayed referral, and antimalarial misuse, yet excluding these providers ignores their de facto role. The authors advocate pragmatic, regulated engagement: minimum standards for diagnosis, treatment, referral, reporting, training, and monitoring among participating providers, consistent with national regulations and accompanied by quality-assurance mechanisms. They further highlight the potential of Female Health Workers, whose formalization within the national primary healthcare system could improve household-level access where gender norms, insecurity, or social barriers limit facility-based care.

The review’s policy roadmap is phased by feasibility and time horizon. Immediate priorities include strengthening existing community-based services through standardized supervision, referral pathways, reliable availability of rapid diagnostic tests and antimalarial medicines, and linking community reporting to routine surveillance. Short-to-medium-term priorities focus on institutionalizing the community health workforce through a nationally coherent framework for recruitment, training, supervision, incentives, and career progression, including a workforce registry. Medium-term priorities center on integrated surveillance and interoperable digital platforms that connect community reporting, facility data, commodity monitoring, and environmental information. Longer-term priorities address sustainable financing and government stewardship, with the goal of shifting from parallel, project-specific delivery toward a coordinated model in which government institutions provide strategic leadership while partners contribute within a nationally aligned framework. The authors stress that Uganda’s model should be adapted, not replicated: the transferable principles are government ownership, standardized supervision, facility linkage, routine commodity management, and community-level surveillance, all of which must be tailored to Somalia’s conflict-affected, climate-vulnerable, mobile, and decentralized context. Malaria control in Somalia, they conclude, is fundamentally a health-system and governance challenge, and durable progress will require a gradual transition from fragmented, project-based interventions toward an integrated, government-led primary healthcare system capable of withstanding the interconnected shocks of climate variability, displacement, and insecurity.

Subject of Research: Community health worker models and One Health-informed strategies for strengthening malaria control and health-system resilience in Somalia, drawing on Uganda's integrated community case management experience

Article Title: Strengthening malaria control in Somalia: lessons from Uganda’s One Health model for community-based service delivery and health-system resilience

Article References: Ahmed, N. S., Ibrahim, F. A., & Ali, O. A. (2026). Strengthening malaria control in Somalia: lessons from Uganda’s One Health model for community-based service delivery and health-system resilience. Frontiers in Tropical Diseases, 7, Article 1952696. https://doi.org/10.3389/fitd.2026.1952696

Image Credits: AI Generated

DOI: 10.3389/fitd.2026.1952696

Keywords: malaria, Somalia, Uganda, community health workers, One Health, integrated community case management, health-system resilience, primary healthcare, surveillance, digital health, climate variability, fragile states