The findings highlight Somalia's medical education and regulatory framework, which is crucial for achieving Sustainable Development Goals and universal health coverage. Despite a notable increase in the number of medical schools, regulatory mechanisms have struggled to keep pace, resulting in concerns about quality and standardization. Alarmingly, only 25 of the 94 medical schools hold international accreditation, posing risks to patient safety and diminishing the recognition of qualifications obtained from Somali institutions. The concentration of medical schools in urban areas, particularly in Benadir, underscores the need for a more equitable distribution of educational resources to ensure access to high-quality medical education nationwide.
Assessment of the health workforce reveals a significant shortage of skilled health professionals, with the current density falling below the World Health Organization's minimum threshold. The pronounced urban-rural disparity in the distribution of health workers further exacerbates the challenges in healthcare service delivery. The ratio of physicians to nurses and midwives (1:5) emphasizes that nurses and midwives play a crucial role in the healthcare system. However, the overall shortage of healthcare providers, as evidenced by the gap analysis based on WHO's recommended density rates, calls for urgent policy interventions to address this critical issue.
These findings are consistent with those of studies conducted in other countries. A study in Kenya reported a similar shortage of healthcare workers, with a density of 1.5 physicians and 7.9 nurses and midwives per 10,000 population, falling short of the WHO's recommended threshold (19). Similarly, a study in Tanzania highlighted the uneven distribution of healthcare workers, with a higher concentration in urban areas and scarcity in rural regions (20). These studies underscore the common challenges faced by the healthcare systems in East Africa, emphasizing the need for collaborative efforts to address the shortage and maldistribution of healthcare professionals.
Focus group discussions with young physicians have shed light on employment challenges faced by medical graduates. The lack of fair and transparent recruitment processes, coupled with the need for strong connections and family linkages, hinders the entry of qualified professionals into the workforce. Limited employment opportunities in both the public and private sectors, along with financial constraints in establishing independent clinics, force many graduates to seek alternative careers or to remain unemployed. This brain drain and underutilization of medical expertise pose a significant threat to the healthcare system's sustainability and effectiveness.
Similar challenges have also been reported in other countries. A study in Uganda found that medical graduates faced difficulties securing employment due to limited job opportunities and nepotism during the recruitment process (21). The study also highlighted the financial barriers faced by young physicians in establishing private practices, leading to a significant proportion of graduates opting for non-medical careers. These findings emphasize the need for policy interventions to create an enabling environment for the absorption of medical graduates into the health care workforce.
The Employment and Education Perception Survey provided valuable insights into the perspectives of healthcare students. While most respondents expressed satisfaction with the quality of their training, dissatisfaction among students in the Benadir Regional Administration (BRA) warrants further investigation. The strong preference for studying within Somalia highlights the need for the standardization of academic training experiences across the country. The perceived employment opportunities among students contradict the experiences of practicing physicians, indicating a potential mismatch between expectations and reality. The willingness of students to work in rural areas, given the right conditions, presents an opportunity to address the urban-rural disparity in healthcare service provision.
Analysis of the Somali HRH regulation landscape revealed several critical challenges. The insufficient capacity of HRH teams at both the federal and state levels hinders the effective implementation of regulatory functions. The absence of a comprehensive regulatory framework has led to reliance on self-regulation by professional associations, which lack the necessary authority and influence to enforce standards and ensure their quality. The lack of licensing exams and continuing professional development opportunities further compromises the competence and skills of healthcare professionals.
However, these regulatory challenges are not unique to the Somalia. A study in Rwanda identified similar gaps in the regulatory framework, including the absence of a comprehensive licensing system and a limited capacity for regulatory oversight (22). The study emphasized the importance of strengthening regulatory bodies and developing clear guidelines for professional practice. These findings highlight the need for a robust regulatory framework to ensure the quality and safety of health care services.
The absence of accreditation for pre-service educational institutions creates inconsistencies in the quality and duration of training programmes, leading to variations in graduate competencies. A study in Ethiopia reported similar challenges, with a lack of standardization in medical education curricula and limited quality assurance mechanisms. This study recommends the establishment of a national accreditation system to ensure the quality and relevance of medical education programs (23). These findings underscore the importance of accreditation for ensuring the production of competent healthcare professionals.
The prevalence of professional misconduct, particularly involving charlatans, undermines public trust in the healthcare system and poses risks to patient safety. The widespread dual practice, which supplements low public salaries, requires careful monitoring and regulation to ensure the quality of care. Similar challenges have also been reported in other studies. A study in Kenya found that lack of regulation and oversight of private healthcare facilities contributed to the proliferation of unqualified practitioners and compromised patient safety (24). The study emphasized the need for strengthened regulatory mechanisms to curb professional misconduct and ensure the delivery of quality healthcare services.
Investment in capacity building of HRH teams at both the federal and state levels is crucial to enable effective regulatory oversight. The implementation of continuing professional development programs, as mandated by the NHPC Act, will help to maintain and enhance the skills and knowledge of healthcare professionals. Collaboration between the Ministry of Health, the Ministry of Education, and professional associations is essential to harmonize training standards and ensure the alignment of educational programs with the healthcare system's needs.
Efforts to address these challenges include enactment of the National Health Professionals' Council (NHPC) Act, which aims to support regulatory oversight and standardize health professional education and practice. However, capacity constraints, inadequate professional development opportunities, and absence of licensing examinations continue to hinder progress in this sector.
There is a significant lack of stakeholder engagement, which has resulted in outdated curricula failing to align with the country's healthcare needs and priorities. The lack of a structured approach involving key stakeholders, such as healthcare providers, policymakers, educators, and community representatives, has led to insufficient resources and a disconnect between educational content and the realities of healthcare delivery in Somalia.
Our findings are consistent with those of previous studies, which have highlighted the importance of stakeholder engagement in curriculum development. One study conducted in Namibia emphasized that curriculum development is an ongoing process involving a wide range of stakeholders, including professional educators, consultants, administrators, teachers, students, parents, politicians, and community members (25).
In contrast, a study conducted in Kenya found that Kenya successfully implemented stakeholder engagement models in its medical education system. A significant majority of institutional heads and faculty members in Kenya reported having written guidelines for curriculum review, ensuring that educational content remains responsive to national health needs and aligns with regulatory standard (26). This finding suggests that by adopting a stakeholder-driven approach like Kenya's, Somalia could rejuvenate its medical education system and ensure that curricula are consistently updated, relevant, and adequately prepare students to tackle healthcare challenges effectively.
The study acknowledges several limitations, including the potential for selection bias in the recruitment of key informants and the reliance on self-reported data in surveys and interviews, which may be subject to social desirability bias. Additionally, the generalizability of the findings may be limited due to the specific context of Somalia. Future research could address these limitations by employing random sampling techniques and triangulating self-reported data with objective measures where possible.