Prolonged multisectoral aid-driven reliance on health systems and governance post-conflict era in Somalia

The global development discourse primarily emphasizes the vital role of international aid in post-conflict health systems and governance. Somalia's post-conflict health recovery has relied heavily on multisectoral aid that saved lives but entrenched parallel systems. While the national budget rose from ~ SOS 200 million (2015) to ~ SOS 1.3 billion (2025), the Ministry of Health's share remained ≤ 7%, leaving sustainability and local ownership at risk. Recent funding cuts have reduced food, health, and WASH services, heightening disease and malnutrition risks. This review examines the long-term impacts of multisectoral aid on Somalia's health system and governance, focusing on its effectiveness, sustainability, and unintended consequences.

We conducted a narrative review (1990-2024; final search April 25, 2025) across PubMed, Scopus, Web of Science, Google Scholar, and gray literature (WHO, UNICEF, World Bank, USAID, FMoH). Using SANRA guidance, two reviewers screened 221 records plus prior evidence; 334 studies/reports were synthesized via hybrid thematic coding (NVivo) across five domains: aid-driven system development; aid-governance interactions; consequences of dependency; comparative insights; and sustainability pathways.

Aid delivered tangible "fruits": expanded immunization and MCH coverage; high 2024 delivery performance (health 95% with US$69.8 M spent; nutrition 95.5% with US$73.9 M); and total donor inflows of ~ US$721.9 M fully deposited. However, most funds flowed off-budget through vertical programs and parallel supply/data chains, fragmenting governance and dampening state capacity. Despite the health share peaking at 7% (2023) and stabilizing near 6.8% (2025), cuts in 2025 curtailed essential services, leaving millions more vulnerable. Comparative cases (Liberia, Sierra Leone vs. South Sudan, Afghanistan) show sustainability improves when pooled funding, government payroll integration, and PHC-first strategies are adopted.

For Somalia to transition from aid dependency to sustainable health governance, a deliberate shift is needed by strengthening FMoH leadership, funding PHC, unifying systems, integrating staff into public payroll, and ensuring epidemic readiness.