{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,1]],"date-time":"2026-09-01T06:15:14Z","timestamp":1788243314152,"version":"build-2803163510"},"reference-count":51,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,9,1]],"date-time":"2026-09-01T00:00:00Z","timestamp":1788220800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Health Serv."],"abstract":"<jats:p>Health-system resilience is a major policy concern in fragile and conflict-affected settings, where recurrent shocks intersect with chronic weaknesses in governance, financing, workforce, service delivery, information systems, and supply chains. This policy and practice review synthesizes 51 peer-reviewed and institutional sources published or issued between 1990 and 3 July 2026 to examine how Somalia's health system has responded to three decades of conflict, climatic emergencies, displacement, outbreaks, and humanitarian intervention. Sources were identified through targeted searches of PubMed\/MEDLINE, Google Scholar, and authoritative institutional repositories and interpreted using the World Health Organization health-system building blocks and contemporary resilience concepts. The review distinguishes absorptive, adaptive, and transformative resilience from temporary emergency adaptation and donor-dependent response capacity using explicit decision rules concerning service continuity, duration, financing and ownership, integration into routine systems, and evidence of learning and accountability. Somalia has accumulated important resilience-enabling capacities, including community-based surveillance, outbreak-response learning, expansion of the District Health Information Software 2, national strategic planning, and the Community Health Strategy 2025\u20132029. However, chronic underfinancing, fragmented governance and service delivery, workforce shortages, weak supply chains, incomplete private-sector stewardship, inequitable access, and uneven primary health-care readiness continue to limit institutional resilience. The review proposes seven actionable priorities: a unified national resilience framework; predictable and aligned financing; primary health-care readiness and continuity planning; professionalized community health platforms; private-sector integration into regulation, referral, and reporting; climate-health, nutrition, and water, sanitation and hygiene preparedness; and an operational resilience dashboard linked to decision triggers and actor accountability. These priorities are policy inferences derived from Somalia-specific operational evidence, national strategies, and wider fragile-setting literature rather than causally proven interventions. Given binding fiscal and data constraints, implementation should be phased, costed, and begin with functions and indicators that can be sustained through existing routine systems. Somalia should therefore not yet be described as having a fully resilient health system. Durable resilience will depend on embedding recurrent emergency adaptations within financed, governed, measurable, equitable, and routinely functioning primary health-care and public-health institutions.<\/jats:p>","DOI":"10.3389\/frhs.2026.1934074","type":"journal-article","created":{"date-parts":[[2026,9,1]],"date-time":"2026-09-01T05:35:56Z","timestamp":1788240956000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["From emergency adaptation to institutional resilience: a policy and practice review of Somalia's health system, 1991\u20132026"],"prefix":"10.3389","volume":"6","author":[{"given":"Nor Haji","family":"Osman","sequence":"first","affiliation":[{"name":"Department of Public Health, Faculty of Health Sciences, Al Hayat Medical University","place":["Mogadishu, Somalia"]},{"name":"Department of Policy and Planning, Directorate of Health and Human Services","place":["Mogadishu, Somalia"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hamdi Mohamud","family":"Osman","sequence":"additional","affiliation":[{"name":"Noncommunicable Diseases Section, Ministry of Health and Human Services","place":["Mogadishu, Somalia"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Abdifatah Nour","family":"Rage","sequence":"additional","affiliation":[{"name":"Department of Social Sciences, Faculty of Humanities and Social Sciences, Salaam University","place":["Mogadishu, Somalia"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Abdiweli Mohamed","family":"Abdi","sequence":"additional","affiliation":[{"name":"Department of Public Health, Faculty of Health Sciences, Al Hayat Medical University","place":["Mogadishu, Somalia"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mohamed Ismail","family":"Iman","sequence":"additional","affiliation":[{"name":"Department of Medicine, Faculty of Medicine and Surgery, Al Hayat Medical University","place":["Mogadishu, Somalia"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Aweys Ahmed","family":"Moallim","sequence":"additional","affiliation":[{"name":"Department of Policy and Planning, Directorate of Health and Human Services","place":["Mogadishu, Somalia"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Abdirahman Mohamed","family":"Jimale","sequence":"additional","affiliation":[{"name":"Department of Policy and Planning, Directorate of Health and Human Services","place":["Mogadishu, Somalia"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mohamed Ahmed","family":"Ali","sequence":"additional","affiliation":[{"name":"Department of Policy and Planning, Directorate of Health and Human Services","place":["Mogadishu, Somalia"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ismail Dahir","family":"Ahmed","sequence":"additional","affiliation":[{"name":"Department of Administration, Human Resources and Capacity Building, Directorate of Health and Human Services","place":["Mogadishu, Somalia"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Abdikarim Abdi","family":"Adam","sequence":"additional","affiliation":[{"name":"Department of Environmental Health and Climate, IPC Section, Federal Ministry of Health and Human Services","place":["Mogadishu, Somalia"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Abdirahman Ahmed","family":"Mohamud","sequence":"additional","affiliation":[{"name":"Department of Health, Directorate of Health and Human Services","place":["Mogadishu, Somalia"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Siham Mohamed","family":"Dhakane","sequence":"additional","affiliation":[{"name":"Department of Public Health, Faculty of Health Sciences, Zamzam University of Science and Technology","place":["Mogadishu, Somalia"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Osman Mohamed","family":"Mohamud","sequence":"additional","affiliation":[{"name":"Department of Medicine, Faculty of Medicine and Health Sciences, Zamzam University of Science and Technology","place":["Mogadishu, Somalia"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,9,1]]},"reference":[{"key":"B1","volume-title":"Health Systems Resilience Toolkit: A wHO Global Public Health Good to Support Building and Strengthening of Sustainable Health Systems Resilience in Countries with various Contexts","year":"2022"},{"key":"B2","volume-title":"Ready for the Next Crisis? Investing in Health System Resilience","year":"2023"},{"key":"B3","doi-asserted-by":"publisher","first-page":"964","DOI":"10.1038\/s41591-021-01381-y","article-title":"Health systems resilience in managing the COVID-19 pandemic: lessons from 28 countries","volume":"27","author":"Haldane","year":"2021","journal-title":"Nat Med"},{"key":"B4","doi-asserted-by":"publisher","first-page":"1910","DOI":"10.1016\/S0140-6736(15)60755-3","article-title":"What is a resilient health system? Lessons from ebola","volume":"385","author":"Kruk","year":"2015","journal-title":"Lancet"},{"key":"B5","doi-asserted-by":"publisher","first-page":"iii91","DOI":"10.1093\/heapol\/czx118","article-title":"From bouncing back, to nurturing emergence: reframing the concept of resilience in health systems strengthening","volume":"32","author":"Barasa","year":"2017","journal-title":"Health Policy Plan"},{"key":"B6","doi-asserted-by":"publisher","first-page":"1310","DOI":"10.1186\/s12889-019-7707-z","article-title":"What makes health systems resilient against infectious disease outbreaks and natural hazards? Results from a scoping review","volume":"19","author":"Nuzzo","year":"2019","journal-title":"BMC Public Health"},{"key":"B7","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1186\/s13031-023-00560-7","article-title":"Health systems resilience in fragile and conflict-affected settings: a systematic scoping review","volume":"18","author":"Truppa","year":"2024","journal-title":"Confl Health"},{"key":"B8","volume-title":"Somalia's Healthcare System: A Baseline Study and Human Capital Development Strategy","year":"2020"},{"key":"B9","volume-title":"Everybody's Business: Strengthening Health Systems to Improve Health Outcomes\u2014wHO's framework for Action","year":"2007"},{"key":"B10","volume-title":"Health Sector Strategic Plan III 2022\u20132026","year":"2021"},{"key":"B11","volume-title":"Somalia Economic Update: Investing in Health to Anchor Growth","year":"2021"},{"key":"B12","volume-title":"Investment Case for the Somali Health Sector 2022\u20132027","year":"2022"},{"key":"B13","volume-title":"Essential Package of Health Services (EPHS) Somalia 2020: Executive Action Document","year":"2021"},{"key":"B14","year":"2026"},{"key":"B15","doi-asserted-by":"publisher","first-page":"98","DOI":"10.1186\/s12961-023-01031-4","article-title":"Resilience of primary healthcare system across low- and middle-income countries during the COVID-19 pandemic: a scoping review","volume":"21","author":"Pradhan","year":"2023","journal-title":"Health Res Policy Syst"},{"key":"B16","doi-asserted-by":"publisher","first-page":"841","DOI":"10.1186\/s12913-024-11278-4","article-title":"Strategies to strengthen the resilience of primary health care in the COVID-19 pandemic: a scoping review","volume":"24","author":"Mosadeghrad","year":"2024","journal-title":"BMC Health Serv Res"},{"key":"B17","doi-asserted-by":"publisher","first-page":"355","DOI":"10.1093\/heapol\/czx183","article-title":"Towards an understanding of resilience: responding to health systems shocks","volume":"33","author":"Hanefeld","year":"2018","journal-title":"Health Policy Plan"},{"key":"B18","doi-asserted-by":"publisher","first-page":"e0318244","DOI":"10.1371\/journal.pone.0318244","article-title":"Contribution of health system governance in delivering primary health care services for universal health coverage: a scoping review","volume":"20","author":"Khatri","year":"2025","journal-title":"PLoS One"},{"key":"B19","doi-asserted-by":"publisher","first-page":"34","DOI":"10.1186\/s12913-025-13802-6","article-title":"Assessing and measuring community health system resilience\u2014an updated scoping review of approaches","volume":"26","author":"Espmark","year":"2026","journal-title":"BMC Health Serv Res"},{"key":"B20","doi-asserted-by":"publisher","first-page":"101240","DOI":"10.1016\/j.lana.2025.101240","article-title":"No time to wait: resilience as a cornerstone for primary health care across Latin America and the Caribbean, a world bank\u2013PAHO lancet regional health\u2014Americas commission","volume":"50","author":"Herrera","year":"2025","journal-title":"Lancet Reg Health Am"},{"key":"B21","doi-asserted-by":"publisher","first-page":"431","DOI":"10.15171\/ijhpm.2017.36","article-title":"Governance and capacity to manage resilience of health systems: towards a new conceptual framework","volume":"6","author":"Blanchet","year":"2017","journal-title":"Int J Health Policy Manag"},{"key":"B22","doi-asserted-by":"publisher","first-page":"168","DOI":"10.1016\/j.socscimed.2019.04.020","article-title":"Conceptual analysis of health systems resilience: a scoping review","volume":"232","author":"Turenne","year":"2019","journal-title":"Soc Sci Med"},{"key":"B23","doi-asserted-by":"publisher","first-page":"7","DOI":"10.1186\/s13031-019-0241-x","article-title":"Understanding the factors affecting the humanitarian health and nutrition response for women and children in Somalia since 2000: a case study","volume":"14","author":"Ahmed","year":"2020","journal-title":"Confl Health"},{"key":"B24","doi-asserted-by":"publisher","first-page":"e1454","DOI":"10.1016\/S2214-109X(23)00279-6","article-title":"Health system resilience: a critical review and reconceptualisation","volume":"11","author":"Witter","year":"2023","journal-title":"Lancet Glob Health"},{"key":"B25","doi-asserted-by":"publisher","first-page":"5","DOI":"10.1186\/s41073-019-0064-8","article-title":"SANRA\u2014a scale for the quality assessment of narrative review articles","volume":"4","author":"Baethge","year":"2019","journal-title":"Res Integr Peer Rev"},{"key":"B26","doi-asserted-by":"publisher","first-page":"45","DOI":"10.1186\/1471-2288-8-45","article-title":"Methods for the thematic synthesis of qualitative research in systematic reviews","volume":"8","author":"Thomas","year":"2008","journal-title":"BMC Med Res Methodol"},{"key":"B27","doi-asserted-by":"publisher","first-page":"37","DOI":"10.1186\/1471-2288-13-37","article-title":"Best fit' Framework synthesis: refining the method","volume":"13","author":"Carroll","year":"2013","journal-title":"BMC Med Res Methodol"},{"key":"B28","doi-asserted-by":"publisher","first-page":"39","DOI":"10.1186\/1741-7015-9-39","article-title":"Using framework-based synthesis for conducting reviews of qualitative studies","volume":"9","author":"Dixon-Woods","year":"2011","journal-title":"BMC Med"},{"key":"B29","volume-title":"Monitoring the Building Blocks of Health Systems: A Handbook of Indicators and Their Measurement Strategies","year":"2010"},{"key":"B30","article-title":"Strengthening health systems resilience: key concepts and strategies","volume-title":"Health System and Policy Analysis Policy Brief 36","author":"Thomas","year":"2020"},{"key":"B31","doi-asserted-by":"publisher","first-page":"14604582261428311","DOI":"10.1177\/14604582261428311","article-title":"Data quality of routine health information systems and associated factors among public health facilities in banadir region, Somalia: a cross-sectional study","volume":"32","author":"Osman","year":"2026","journal-title":"Health Informatics J"},{"key":"B32","volume-title":"Comprehensive Assessment of Somalia's health Information System 2022","year":"2024"},{"key":"B33","doi-asserted-by":"publisher","first-page":"e197","DOI":"10.1016\/S2214-109X(14)70010-5","article-title":"Opportunity for health systems strengthening in Somalia","volume":"2","author":"Warsame","year":"2014","journal-title":"Lancet Glob Health"},{"key":"B34","doi-asserted-by":"publisher","first-page":"1205327","DOI":"10.3389\/fpubh.2024.1205327","article-title":"Implementing health system and the new federalism in Somalia: challenges and opportunities","volume":"12","author":"Said","year":"2024","journal-title":"Front Public Health"},{"key":"B35","doi-asserted-by":"publisher","first-page":"1","DOI":"10.36368\/shaj.v1i1.250","article-title":"Strategies for post-conflict development of the health systems in Somalia: lessons from selected countries","volume":"1","author":"Omar","year":"2021","journal-title":"Somali Health Action J"},{"key":"B36","doi-asserted-by":"publisher","first-page":"127","DOI":"10.2147\/RMHP.S136170","article-title":"Beneficiaries of conflict: a qualitative study of people's Trust in the private health care system in Mogadishu, Somalia","author":"Gele","year":"2017","journal-title":"Risk Manag Healthc Policy"},{"key":"B37","volume-title":"Mortality among Populations of Southern and Central Somalia Affected by Severe Food Insecurity and Famine During 2010\u20132012","author":"Checchi","year":"2013"},{"key":"B38","doi-asserted-by":"publisher","first-page":"e0001136","DOI":"10.1371\/journal.pgph.0001136","article-title":"Drought, armed conflict and population mortality in Somalia, 2014\u20132018: a statistical analysis","volume":"3","author":"Warsame","year":"2023","journal-title":"PLOS Glob Public Health"},{"key":"B39","doi-asserted-by":"publisher","first-page":"734","DOI":"10.26719\/emhj.23.096","article-title":"Responding to cholera outbreaks in Somalia in 2017\u20132019","volume":"29","author":"Lubogo","year":"2023","journal-title":"East Mediterr Health J"},{"key":"B40","volume-title":"Cholera Response Plan","year":"2024"},{"key":"B41","doi-asserted-by":"publisher","first-page":"941","DOI":"10.1093\/cid\/ciy180","article-title":"Strengthening acute flaccid paralysis surveillance through the village polio volunteers program in Somalia","volume":"67","author":"Mbaeyi","year":"2018","journal-title":"Clin Infect Dis"},{"key":"B42","doi-asserted-by":"publisher","first-page":"1215620","DOI":"10.3389\/fpubh.2023.1215620","article-title":"The importance of community health workers as frontline responders during the COVID-19 pandemic, Somalia, 2020\u20132021","volume":"11","author":"Nyagah","year":"2023","journal-title":"Front Public Health"},{"key":"B43","volume-title":"From Insight to Action: An Update on Mortality Patterns in Somalia","year":"2025"},{"key":"B44","doi-asserted-by":"publisher","first-page":"378","DOI":"10.2471\/BLT.19.233965","article-title":"Health systems research in fragile settings","volume":"97","author":"Ager","year":"2019","journal-title":"Bull World Health Organ"},{"key":"B45","volume-title":"Reduction of Somali Health Budget After 2023 Debt Relief a Betrayal","year":"2024"},{"key":"B46","volume-title":"Appropriation Act for 2025 Budget","year":"2025"},{"key":"B47","doi-asserted-by":"publisher","first-page":"5","DOI":"10.1186\/s13561-025-00703-x","article-title":"Burden or benefit? Unveiling the impact of out-of-pocket health expenditures in Somalia's Healthcare system","volume":"16","author":"Mohamud","year":"2026","journal-title":"Health Econ Rev"},{"key":"B48","volume-title":"Somalia Humanitarian Situation Report No. 07\u201309, Reporting Period 1 July\u201330 September 2025","year":"2025"},{"key":"B49","volume-title":"Funding Gaps Undermine Healthcare for Women and Children in Somalia","year":"2025"},{"key":"B50","doi-asserted-by":"publisher","first-page":"209","DOI":"10.1016\/j.socscimed.2019.04.019","article-title":"Health financing in fragile and conflict-affected settings: what do we know, seven years on?","volume":"232","author":"Bertone","year":"2019","journal-title":"Soc Sci Med"},{"key":"B51","volume-title":"Health Financing in fragile and Conflict-affected situations: A Review of the Evidence","year":"2020"}],"container-title":["Frontiers in Health Services"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/frhs.2026.1934074\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,1]],"date-time":"2026-09-01T05:36:00Z","timestamp":1788240960000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/frhs.2026.1934074\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,1]]},"references-count":51,"alternative-id":["10.3389\/frhs.2026.1934074"],"URL":"https:\/\/doi.org\/10.3389\/frhs.2026.1934074","relation":{},"ISSN":["2813-0146"],"issn-type":[{"value":"2813-0146","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,1]]},"article-number":"1934074"}}