Beyond Access: Patient Preferences, Treatment Adherence, and Trust in Healthcare in Post-Conflict Somalia

Health-system reconstruction in post-conflict Somalia has been framed largely around access. This has meant rebuilding facilities, expanding coverage, and restoring supply chains after decades of conflict-driven collapse. This commentary argues that access is necessary but not sufficient to explain whether Somalis use, remain engaged with, and benefit from the care available to them. Drawing on a growing body of Somalia-specific qualitative and cross-sectional evidence, we highlight three underexamined determinants of health outcomes: patient preference, treatment adherence, and trust. An oft-cited estimate holds that roughly 90% of Somalis rely on an unregulated and largely unaccountable private health sector. More recent analyses confirm that this pattern persists. Trust, or its absence, shapes care-seeking as powerfully as physical availability does. Preference is similarly consequential in a pluralistic system where patients continuously choose between public, private, non-governmental organization (NGO)-run, and traditional providers. A system that ignores what patients want from an encounter risks being technically accessible yet practically unused. Left unaddressed, gaps in trust and preference-responsiveness translate into non-adherence. This is particularly so for chronic and non-communicable conditions that require sustained engagement over time. We propose that three elements should be treated as core, measurable components of health-system performance in Somalia: private-sector regulation and quality assurance, systematic elicitation of patient preference, and adherence support built into chronic-care programs from the outset. These should sit alongside continued investment in access.