Universal health coverage in fragile and conflict-affected States: insights from Somalia.

Introduction: Achieving Sustainable Development Goal (SDG) 3, which focuses on health, and more specifically SDG 3.8-universal health coverage (UHC)-by 2030 remains a critical objective for all nations. This paper presents an updated evaluation of Somalia's progress toward UHC. Additionally, by identifying key barriers to achieving UHC in Somalia, this study offers insights that may be valuable for other conflict-affected and post-conflict countries striving to improve healthcare access and financial protection.

Methodology: To assess Somalia's progress at various levels, we developed a UHC index incorporating access to essential healthcare services and financial risk protection. Furthermore, we employed standard analytical methods, including equity analysis and logit modelling, to examine the key factors influencing both healthcare access and the financial burden associated with seeking medical care.

Results: With an overall UHC index score of 33.5, Somalia ranks lowest among the countries previously analysed. While there is some regional variation in UHC scores, these differences are not as pronounced as the disparities in poverty rates, resulting in a weak correlation between regional socio-economic development (measured by poverty levels) and overall UHC performance. Equity analysis highlights that socio-economic status, educational attainment, and, to a lesser extent, healthcare infrastructure significantly contribute to disparities in access to essential health services, favouring wealthier populations. Additionally, financial risk protection analysis indicates that the most economically disadvantaged groups are at a higher risk of experiencing catastrophic healthcare expenditures.

Implications: Given Somalia's ongoing security challenges, achieving SDG 3.8 by 2030 remains a formidable task. However, targeted interventions that address key determinants-such as household income, education levels, and healthcare infrastructure-could help improve access to essential health services and reduce financial barriers to care.