The historical arc matters for understanding why. After the 1991 civil war dismantled national health infrastructure, Somalia operated for years without any routine surveillance mechanism at all. The Early Warning Alert and Response Network, or EWARN, was established in 2008 as an emergency-oriented system and became the country’s sole multidisease surveillance mechanism for over a decade. It was deactivated amid conflict before being reactivated in 2017 during a severe drought and cholera emergency. EWARN proved effective at rapid alert generation during crises, but its provisional design was never intended to substitute for a permanent national surveillance architecture. Vertical, disease-specific systems for polio and malaria persisted alongside it, generating duplication and coordination gaps that complicated any coherent national picture of disease activity.

A pivotal shift followed Somalia’s 2016 Joint External Evaluation of International Health Regulations core capacities, which revealed limited or no capacity across nearly all surveillance indicators. That assessment prompted the 2020–2024 National Action Plan for Health Security, which prioritized integrated disease surveillance as the central strategy for closing the gaps. The COVID-19 pandemic then exposed the costs of fragmentation and catalyzed the establishment of incident management structures and emergency operations centers that later became foundational to the Integrated Disease Surveillance and Response system, or IDSR. Somalia formally established a functioning IDSR in 2021, guided by a costed three-year operational plan spanning governance, information technology, laboratory networks, and surveillance-response functions, with the District Health Information Software 2 tracker application selected as the national reporting platform.

The technical results of that transition are measurable. A 2024–2025 mixed-methods evaluation found that all federal member states had achieved functional electronic IDSR at the facility level and met the World Health Organization benchmark of at least 80 percent reporting timeliness and completeness, with the notable exception of the Banaadir region, where timeliness fell to 44 percent. The DHIS2 tracker customization has enabled standardized weekly aggregate reporting from hundreds of facilities and supports automated dashboards for epidemiological bulletin generation. However, the immediate case-based reporting component remains only partially deployed on health workers’ mobile devices, and manual transmission persists in many districts. Data generation, in other words, has outpaced data utilization.

The most striking quantitative indicator of that imbalance is alert verification. Only 46.5 percent of public health alerts reported through IDSR had been verified nationally, with substantial interstate variation ranging from 33 to 67 percent. Verification is the step that separates a raw signal from an actionable outbreak lead; without it, laboratory confirmation, epidemiological investigation, and timely response cannot follow. The 2024 IDSR evaluation explicitly identified poor laboratory capacity and weak linkage between surveillance data and laboratory confirmation as recurring implementation barriers across all federal member states. Specimen transport networks between peripheral facilities and regional reference laboratories remain limited, and diagnostic capacity beyond Mogadishu is thin, which delays confirmation of suspected events even when alerts are generated promptly.

Community-based and event-based surveillance, both essential complements to facility reporting for detecting signals from informal and hard-to-reach populations, remained non-operational nationally as of late 2024. This is a significant structural gap in a country where more than 2.6 million internally displaced persons live largely outside routine facility catchment areas, and where nomadic pastoralist communities move across vast territories. Evidence from Somaliland demonstrates what is feasible: a community-based surveillance program using trained community health volunteers and an SMS-based reporting platform generated 138 signals in a single year, with 83 percent verified and escalated to health authorities within 24 hours, triggering interventions such as oral rehydration distribution. Scaling that model nationally, the review argues, could close detection gaps that facility-based reporting alone cannot reach.

The disease burden driving these surveillance demands is itself compound. During the first months of 2024, more than 4,380 cholera cases and 54 deaths were reported across 32 districts, with a case fatality rate of 1.2 percent. Measles remains endemic, with routine immunization coverage estimated at approximately 20 percent, leaving substantial numbers of children susceptible. Between September 2021 and January 2023, officers trained through the Field Epidemiology Training Program investigated 54 measles outbreaks, of which 50 were confirmed, alongside 17 cholera outbreaks. Polio transmission, including circulating vaccine-derived poliovirus, has persisted despite repeated vaccination activities. Tuberculosis remains a major burden, with WHO estimating approximately 43,000 incident cases and 11,000 deaths in a recent reporting year. Malaria and other vector-borne diseases are shifting with changing rainfall and temperature patterns, and Somalia’s extensive human-livestock interaction creates zoonotic risks that a predominantly human-health surveillance system does not adequately capture.

Beneath these technical gaps lie structural constraints that reinforce one another. Governance fragmentation distributes outbreak authority across six federal member states and numerous partners, producing duplicated assessments, delayed release of essential commodities, and inconsistent application of technical guidelines across jurisdictions. Financing is perhaps the most binding constraint: international donors cover roughly half of national health expenditure, and IDSR implementation surveys identified financing as the weakest thematic area, scoring only 15 percent progress against WHO benchmarks. Human resources scored 16 percent in the same assessment, reflecting a health worker density of fewer than 0.4 doctors, nurses, and midwives per 10,000 population against a WHO minimum threshold of 23 per 10,000. Security instability and humanitarian access constraints intersect with all of these deficits, interrupting supportive supervision, disrupting cold-chain logistics, and creating persistent blind spots precisely where outbreak risk is highest.

The review is nonetheless careful to distinguish between what Somalia lacks and what it has demonstrated it can do. Large-scale vaccination campaigns reaching more than 1.7 million children for polio and 1.5 million for measles show that substantial operational capacity can be mobilized when resources, coordination, and implementation align. The Field Epidemiology Training Program has graduated six cohorts by early 2025, with trainees investigating 95 outbreaks between September 2021 and January 2023, though only 51 percent were investigated within 48 to 72 hours of alert. Ten graduates from the first cohort became co-mentors, building national mentoring capacity, and the sixth cohort focused specifically on immunization service delivery and laboratory system strengthening. The challenge, the authors conclude, is not the absence of response capacity but its continuity and integration with routine surveillance and prevention systems.

The strategic prescription that emerges is one of sequencing rather than simultaneous transformation. In the short term, the priorities are consolidating existing IDSR gains: raising alert verification rates beyond the current 46.5 percent national average, closing the timeliness gap in underperforming states, and completing nationwide deployment of mobile case-based reporting. Medium-term priorities include scaling the Field Epidemiology Training Program toward intermediate and advanced tiers, institutionalizing community-based and event-based surveillance nationally, and revitalizing multisectoral technical working groups that have shown declining engagement. Long-term priorities require transitioning toward predictive surveillance that integrates climate, laboratory, and epidemiological data streams to anticipate outbreaks before case counts rise, alongside securing sustainable domestic financing. Digital technologies, the review insists, should be treated as enabling tools within a mature surveillance architecture rather than substitutes for the core capacities of verification, laboratory confirmation, and investigation. Somalia’s next phase of health-security development, the authors suggest, should be judged not by how much data the system generates but by how effectively that information leads to timely action and reduced outbreak risk.

Subject of Research: Infectious disease surveillance and outbreak preparedness in Somalia

Article Title: From detection to response: a critical narrative review of infectious disease surveillance and outbreak preparedness in Somalia

Article References: Abdi, M. S., Abdi, Y. H., & Bashir, S. G. (2026). From detection to response: a critical narrative review of infectious disease surveillance and outbreak preparedness in Somalia. Frontiers in Tropical Diseases, 7, Article 1951505. https://doi.org/10.3389/fitd.2026.1951505

Image Credits: AI Generated

DOI: 10.3389/fitd.2026.1951505

Keywords: Somalia, disease surveillance, outbreak preparedness, Integrated Disease Surveillance and Response, International Health Regulations, cholera, measles, polio, One Health, Field Epidemiology Training Program, health security, fragile states