The scale of unmet need is staggering. Approximately 5.4 million Somalis, including 1.3 million pregnant and breastfeeding women, urgently require health services, yet only 30 percent of public health facilities are fully functional. Three decades of conflict, recurrent climate shocks, and widespread displacement have converged to produce a system that is simultaneously fragile and overstretched. Between January and September 2025 alone, cholera affected more than 8,180 people, measles resurged with nearly 8,512 reported cases, and a diphtheria outbreak infected over 2,445 people, predominantly unvaccinated children. Against this backdrop, 95 percent of Somalia’s health budget depends on external financing, and funding cuts threaten the closure of 618 health facilities by 2026.

In this environment, the authors contend, CHWs who share cultural identities and lived experiences with the communities they serve are uniquely positioned to bridge the gap between vulnerable populations and the formal health system. In Somalia, the term refers primarily to Female Health Workers, known locally as Marwo Caafimaad, who deliver integrated maternal, newborn, and child health services at the household level, conduct community surveillance, and serve as the primary link between communities and formal care. The definition aligns with the Community Health Strategy 2025-2029, which establishes these workers as the anchor cadre of the country’s community health system.

The historical trajectory of this workforce is instructive. The Marwo Caafimaad program was conceived during the development of a joint WHO-UNICEF proposal for Somali health system strengthening submitted to GAVI in 2009. A pilot phase trained and deployed 200 Female Health Workers across Somaliland, Puntland, and Central South Somalia to generate evidence on appropriateness and effectiveness. The GAVI proposal was approved in May 2010, the grant agreement was signed in September 2011, and the program officially began on 1 September 2011. Its vision was explicit: better health for Somali women, girls, and children through high-quality integrated services delivered at the doorsteps of communities, bridging the gap between the health system and the people it serves.

The operational model is demanding. Each CHW trained over 12 months covers approximately 600 to 1,000 people and conducts five to seven home visits per day, providing antenatal care, childhood immunization, common illness treatment, and reproductive health services while also tracking births, deaths, and population mobility. The model directly addresses stark service gaps: only 7 percent of pregnant women receive four or more antenatal visits, and nomadic and rural women face 70 to 90 percent lower odds of adequate care than their urban counterparts. Global evidence underscores that the cultural alignment of female CHWs facilitates household access and sensitive health discussions, while digital feedback mechanisms enhance accountability when coupled with trust-building.

The international literature reinforces the approach. A systematic review of 55 studies across 19 conflict-affected and fragile settings found that CHW-delivered interventions are not only effective but efficient in circumventing access barriers, leveraging physical proximity and social connection to strengthen disease detection, improve care-seeking, and enhance treatment adherence. In maternal and child health, CHWs have delivered effective preventive interventions including breastfeeding promotion, essential newborn care, and malaria prevention. A separate review focused on child undernutrition in fragile settings identified key barriers, such as program disruption during active conflict and weak links between community interventions and public health systems, alongside facilitators including community connection, program proximity, supervision, and investment in high-quality training and tools.

Recent Somali data demonstrate tangible results. A community-based maternal and newborn care program in rural Galmudug, delivered through 34 CHWs serving 1,165 women over 24 months, achieved strong acceptability, with participants reporting trust in CHWs and tangible improvements in pregnancy health knowledge. Coverage was broad, with 88 percent of women who delivered during the program period enrolled, and CHW competency improved markedly, with average assessment scores reaching 94 percent. Quantitative analysis of DHIS2 health data revealed significant gains in districts exposed to governance innovations: antenatal care coverage rose from 30 percent in 2018 to 60 percent in 2023, skilled birth attendance climbed from 20 percent to 35 percent, and DPT3 immunization completion improved from 25 percent to 40 percent, with difference-in-differences estimates indicating net gains of 15 percentage points for each indicator.

CHWs have also proven their worth in epidemic intelligence. During the COVID-19 pandemic, community-based surveillance involving CHWs identified approximately one-third of suspected cases and demonstrated higher positivity rates than facility-based surveillance, with far greater contact tracing yield, 13,279 contacts compared with 1,937. This capacity for early detection is critical in a country where outbreak control increasingly hinges on integrating climate adaptation with health system strengthening, including mobile vaccination and surveillance linked to hydrometeorological alerts. Flooding that exacerbates waterborne disease transmission illustrates why a community-based workforce capable of early warning, rapid response, and health promotion is indispensable in the most vulnerable settlements.

Mental health represents another neglected frontier where CHWs could transform access. An estimated one in three Somalis is affected by some form of psychological disorder, yet 80 to 90 percent of those with mental health problems lack access to good-quality, affordable care, and the average time to first treatment contact is 3.5 years. Only six psychiatrists serve the entire country, and stigma surrounding mental illness remains widespread. A systematic review highlighted in the commentary emphasizes the ability of CHWs to deliver effective mental health care for populations affected by conflict-related trauma, including PTSD, positioning them as a feasible and culturally acceptable cadre for screening, basic psychosocial support, and referral within the mhGAP framework.

The policy environment is shifting. The Somalia Community Health Strategy 2025-2029 marks a landmark move toward professionalizing and integrating the CHW workforce under government leadership, establishing a harmonized national system anchored by trained and certified Female Health Workers and aligning with Africa’s continental target of a two-million-strong community health workforce by 2030. The Pandemic Fund has awarded 24.98 million US dollars to strengthen prevention, preparedness, and response capacities in Somalia, mobilizing an additional 99.6 million dollars in co-financing and 18.4 million dollars in government co-investment. Yet significant challenges persist: historically inconsistent integration into national systems, variable supervision, fragmented external support, and heavy donor dependency, with the Ministry of Health receiving less than 7 percent of the national budget. The authors call for formal recognition of CHW roles within the Essential Package of Health Services, standardized national training and certification, supervision linked to district health systems, integration into national budgeting, and stronger community accountability. They caution that Somalia-specific evidence remains sparse and largely uncontrolled, making conclusions hypothesis-generating rather than definitive. Still, their message is clear: CHWs alone cannot resolve systemic health challenges, but deliberate investment in their capacity and integration could anchor the resilience Somalia’s health system so desperately needs.

Subject of Research: The role of community health workers in strengthening health system resilience in Somalia

Article Title: Strengthening health system resilience in Somalia: The role of community health workers

Article References: Rage, A. N., Ahmed, A. A., Mohamed, M. A., Mohamed, A. A., & Nor, M. H. (2026). Strengthening health system resilience in Somalia: The role of community health workers. Public Health in Practice, 12, Article 100865. https://doi.org/10.1016/j.puhip.2026.100865

Image Credits: AI Generated

DOI: 10.1016/j.puhip.2026.100865

Keywords: community health workers, Somalia, health system resilience, primary health care, Female Health Workers, maternal health, disease surveillance, fragile settings, mental health, immunization, health policy, pandemic preparedness