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Peer-reviewedCC BY 4.0Frontiers in Public Health

Out-of-pocket health expenditures as a barrier to healthcare access, financial protection, and progress toward universal health coverage: a narrative review from Somalia

  • Sharmake Gaiye Bashir1
  • Ilyas Abdullahi khalif1
  • Mohamed Sharif Abdi1
  • Yakub Burhan Abdullahi1
  1. 1Department of Public Health, Faculty of Medicine and Health Science, Hormuud University
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Abstract

Universal health coverage (UHC) requires both access to needed services and protection from financial hardship, yet Somalia's health system depends heavily on out-of-pocket (OOP) payments. This narrative review synthesizes recent evidence on the magnitude, drivers, and consequences of OOP spending in Somalia and identifies policy options to strengthen financial protection. OOP payments account for 44.9% of total health expenditure, far above the global (18.6%) and sub-Saharan African (35.7%) averages, while government financing and insurance coverage of about 3.5% remain minimal. Weak public financing, a dominant and largely unregulated private sector, and fragmented donor aid sustain this reliance. Roughly 24% of households experience catastrophic health expenditure, commonly resorting to borrowing, asset sales, and reduced consumption, and many forgo care altogether. These burdens fall disproportionately on the poor, women, rural populations, and internally displaced persons, leaving Somalia with the lowest UHC index among 120 countries at 33.5. Experiences from Rwanda, Ghana, and Ethiopia show that reducing OOP reliance depends on increased public financing, pooled prepayment, and pro-poor subsidies rather than insurance laws alone, supporting a phased, subsidy-backed reform agenda.

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Cite

BibTeXRIS
BibTeX
@article{bashir2026outofpocket,
  title = {{Out-of-pocket health expenditures as a barrier to healthcare access, financial protection, and progress toward universal health coverage: a narrative review from Somalia}},
  author = {Sharmake Gaiye Bashir and Ilyas Abdullahi khalif and Mohamed Sharif Abdi and Yakub Burhan Abdullahi},
  journal = {Frontiers in Public Health},
  year = {2026},
  month = oct,
  doi = {10.3389/fpubh.2026.1917671},
  url = {https://www.frontiersin.org/articles/10.3389/fpubh.2026.1917671/full},
  note = {CC BY 4.0},
}
RIS
TY  - JOUR
TI  - Out-of-pocket health expenditures as a barrier to healthcare access, financial protection, and progress toward universal health coverage: a narrative review from Somalia
AU  - Sharmake Gaiye Bashir
AU  - Ilyas Abdullahi khalif
AU  - Mohamed Sharif Abdi
AU  - Yakub Burhan Abdullahi
PY  - 2026
DA  - 2026/10/13
JO  - Frontiers in Public Health
DO  - 10.3389/fpubh.2026.1917671
UR  - https://www.frontiersin.org/articles/10.3389/fpubh.2026.1917671/full
AB  - Universal health coverage (UHC) requires both access to needed services and protection from financial hardship, yet Somalia's health system depends heavily on out-of-pocket (OOP) payments. This narrative review synthesizes recent evidence on the magnitude, drivers, and consequences of OOP spending in Somalia and identifies policy options to strengthen financial protection. OOP payments account for 44.9% of total health expenditure, far above the global (18.6%) and sub-Saharan African (35.7%) averages, while government financing and insurance coverage of about 3.5% remain minimal. Weak public financing, a dominant and largely unregulated private sector, and fragmented donor aid sustain this reliance. Roughly 24% of households experience catastrophic health expenditure, commonly resorting to borrowing, asset sales, and reduced consumption, and many forgo care altogether. These burdens fall disproportionately on the poor, women, rural populations, and internally displaced persons, leaving Somalia with the lowest UHC index among 120 countries at 33.5. Experiences from Rwanda, Ghana, and Ethiopia show that reducing OOP reliance depends on increased public financing, pooled prepayment, and pro-poor subsidies rather than insurance laws alone, supporting a phased, subsidy-backed reform agenda.
SN  - 2296-2565
ER  -