Strengthening malaria control in Somalia: lessons from Uganda’s One Health model for community-based service delivery and health-system resilience

1 Introduction

Malaria remains one of the most important infectious diseases globally, despite substantial progress in prevention, diagnosis, treatment, surveillance, and vector control over the past two decades. Since 2000, major investments in malaria interventions have averted an estimated 2.3 billion malaria cases and 14 million deaths globally, including approximately 1 million lives saved in 2024 alone. Nevertheless, malaria transmission remains highly concentrated in sub-Saharan Africa, where persistent inequalities in healthcare access, poverty, conflict, population displacement, climatic variability, and health-system weaknesses continue to constrain progress toward elimination (1–3, 48). The persistence of malaria in these settings demonstrates that biomedical interventions alone are insufficient and that sustainable control also depends on resilient primary healthcare systems, effective surveillance, community engagement, and reliable delivery of preventive and curative services (4–6, 48).

The burden is particularly severe in the WHO African Region. In 2024, an estimated 282 million malaria cases and 610,000 malaria deaths occurred globally, with approximately two thirds of global cases and deaths concentrated in 11 African countries, including Uganda (48). Between 2015 and 2024, malaria case incidence and mortality declined in the African Region, but the pace of progress remained insufficient to meet global targets (2, 48). These trends highlight the continuing importance of context-specific strategies that combine vector control, diagnostic testing, effective antimalarial treatment, surveillance, community-based service delivery, and health-system strengthening (3, 8, 48). In high-burden and fragile settings, the effectiveness of these interventions depends heavily on whether communities can consistently access trained health workers, essential commodities, referral services, and functioning health facilities (5, 9, 10).

Uganda provides an important regional example of sustained malaria-control implementation and community-based service delivery. The country has developed successive malaria-control strategies incorporating insecticide-treated nets, indoor residual spraying, diagnostic testing, effective antimalarial treatment, surveillance, and community-level interventions (30–32, 48). Community health workers, particularly Village Health Teams (VHTs), have played an important role in extending essential services to populations that experience geographical and socioeconomic barriers to facility-based care (9, 34). Uganda’s experience also demonstrates that community-based malaria services are more effective when CHWs are supported through standardized training, supervision, reliable supplies, referral mechanisms, facility linkages, and institutional coordination (35, 46).

Evidence from Uganda illustrates the importance of these implementation conditions. In western Uganda, long-term implementation of integrated community case management (iCCM) demonstrated that community-level malaria care could achieve substantial levels of appropriate case management when CHWs were embedded within a functioning service-delivery structure (33, 34). One assessment reported a 74% correct-care rate for malaria management, while the broader evidence emphasized the importance of training, supervision, diagnostic and medicine availability, referral pathways, and links between community workers and health facilities (34, 35). Other Ugandan studies similarly indicate that treatment-seeking behavior, community trust, CHW capacity, and health-system support influence the reach and sustainability of community-based malaria interventions (28, 46).

Somalia presents a substantially different health-system context. The country’s health sector has experienced prolonged humanitarian pressures, fragmented financing, dependence on external partners, limited government stewardship, and substantial variation in service availability across geographic areas (19, 54). These structural weaknesses are particularly important for malaria control because prevention, diagnosis, treatment, surveillance, and referral depend on continuous availability of commodities, trained personnel, functioning facilities, and coordinated community-level services (20, 22). Evidence from fragile and conflict-affected settings suggests that disease-control programs are more sustainable when community interventions are integrated into resilient primary healthcare systems rather than implemented solely through short-term vertical programs (5, 13, 54).

Malaria transmission in Somalia is heterogeneous and varies geographically and across population groups. Children younger than five years, pregnant women, rural and remote communities, pastoral populations, and internally displaced populations may face greater barriers to timely diagnosis, treatment, prevention, and referral (17–19, 21). Conflict, insecurity, displacement, weak infrastructure, shortages of health workers, and limited access to essential medicines can further interrupt continuity of malaria services (19–22). These vulnerabilities indicate that strengthening malaria control in Somalia requires more than expanding individual interventions; it requires strengthening the community and primary healthcare systems through which malaria prevention, diagnosis, treatment, surveillance, and referral are delivered (14, 46).

Recent WHO evidence indicates both progress and continuing vulnerability in Somalia’s malaria response. Reported malaria prevalence in the most affected areas declined from 20.1% in 2015 to 4.1% in 2023, while malaria incidence increased from 3.4% in 2022 to 4.0% in 2023 (48). These trends demonstrate the potential contribution of malaria-control interventions while also highlighting the continuing need for reliable surveillance and adaptive service delivery. Somalia’s epidemiological situation is further complicated by climatic variability, population mobility, humanitarian emergencies, and uneven access to health services, all of which can alter malaria risk and complicate timely implementation of control measures (17, 29, 48).

A One Health perspective provides a useful framework for understanding these interconnected determinants. One Health recognizes that human, animal, and environmental health are interdependent and that complex health challenges may require coordinated action across sectors (23–25). Although human malaria is primarily transmitted through mosquito vectors rather than livestock, malaria transmission is influenced by interactions among human populations, vector ecology, environmental conditions, climate variability, and population movement (26, 27).

Consequently, a One Health-informed malaria strategy can provide a broader framework for connecting human health services with environmental and vector surveillance and with relevant community and multisectoral systems (23, 25, 29).

The human-health component of One Health is directly relevant to malaria prevention, diagnosis, treatment, care-seeking, surveillance, and equitable access to health services. In Somalia, these dimensions are shaped by displacement, insecurity, geographic barriers, poverty, limited health infrastructure, and weaknesses in routine community and primary healthcare services (14, 22). Strengthening CHWs and community-based service delivery can therefore contribute not only to malaria case management but also to earlier detection, referral, health education, surveillance, and continuity of care in underserved populations (30, 34, 46).

The animal-health dimension requires careful contextualization in Somalia. Livestock are not the principal reservoir driving human malaria transmission; however, Somalia’s predominantly pastoral and agro-pastoral livelihoods create important human–animal–environment interfaces that influence population mobility, settlement patterns, livelihoods, and access to health services (24, 25, 29). Pastoral mobility may place some populations beyond the reach of conventional facility-based services and can complicate continuity of prevention, diagnosis, treatment, and surveillance (19, 21, 24). A One Health-informed approach should therefore consider the mobility and livelihood systems that shape exposure and healthcare access, while avoiding the incorrect implication that livestock are a major biological reservoir for human malaria.

The environmental-health component is particularly important because temperature, rainfall, flooding, drought, water availability, vegetation, and other ecological conditions can influence mosquito breeding, vector survival, malaria transmission, and population exposure (27, 29). In Somalia, recurrent droughts and floods can simultaneously affect livelihoods, population movement, water access, displacement, and health-service continuity (23, 24, 29). Climate variability may therefore interact with existing health-system weaknesses rather than acting as an isolated determinant of malaria risk. Integrating environmental and climate information with routine malaria surveillance could strengthen early warning, targeted vector-control planning, and preparedness for changing transmission patterns (23, 29, 41).

These human, animal, and environmental dimensions are particularly relevant in Somalia because pastoralism, recurrent climate extremes, displacement, insecurity, and geographic inequalities in healthcare access frequently occur within the same populations and locations (19, 21, 23). The resulting vulnerabilities may reinforce one another: climate-related shocks can contribute to displacement and livelihood disruption, while displacement and weak infrastructure can reduce access to malaria prevention and treatment services (24, 29). A One Health-informed malaria strategy should therefore link routine human malaria surveillance with vector surveillance, climate and environmental information, community-level observations, and appropriate multisectoral preparedness mechanisms (23, 25, 41).

Uganda’s experience should not be interpreted as a model that can be transferred unchanged to Somalia. Rather, it provides evidence on system-level principles that may be adapted to the Somali context, including CHW institutionalization, supervision, training, commodity management, referral, community engagement, surveillance, and government stewardship (33–35, 47). Evidence from conflict-affected settings further supports the importance of integrating community-based disease-control services into resilient primary healthcare structures instead of relying exclusively on fragmented or short-term vertical programs (5, 13, 54). The relevance of Uganda therefore lies in identifying adaptable mechanisms rather than reproducing its institutional arrangements without contextual modification.

Despite the importance of community-based malaria control in both countries, evidence remains uneven (9). Uganda has a relatively broader literature describing CHW implementation, iCCM, supervision, community engagement, and health-system integration (30–35). whereas evidence from Somalia is more limited and frequently shaped by conflict, displacement, humanitarian programming, and fragmented service delivery (17–22, 54). Comparative synthesis is therefore needed to identify which components of Uganda’s experience may be feasible in Somalia, which require substantial adaptation, and where important evidence gaps remain (5, 13). Such an approach is particularly relevant to designing malaria-control strategies that are sustainable, government-led, community-centered, and resilient to environmental and humanitarian shocks (23, 46, 54).

Against this background, this scoping review synthesizes evidence on community-based malaria service delivery and CHW implementation in Somalia and Uganda, focusing on governance, financing, workforce organization, service delivery, surveillance, health-system integration, and One Health-related environmental and vector considerations. By comparing the two settings, the review aims to identify transferable system-level lessons while explicitly accounting for differences in political, security, geographic, humanitarian, and health-system contexts, and to propose a feasible One Health-informed pathway for strengthening malaria control and health-system resilience in Somalia.

2 Methods

2.1 Review design

This study employed a scoping review design to map and synthesize the available evidence on malaria control, community health worker (CHW) implementation, community-based service delivery, and health-system strengthening in Somalia and Uganda. The review focused on evidence related to malaria prevention, diagnosis, treatment, surveillance, community-based interventions, CHW services, health-system integration, and One Health-informed considerations. The review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR).

2.2 Information sources and search strategy

A structured literature search was conducted in Scopus and Web of Science to identify relevant studies addressing malaria control and community-based health service delivery in Somalia and Uganda. The search strategy combined keywords and Boolean operators related to malaria, malaria control, community health workers, community-based service delivery, primary healthcare, health systems, surveillance, vector control, One Health, Somalia, and Uganda.

The search covered studies published between 2000 and 2026. Because 2026 was still ongoing at the time of the search, only records available within the defined search period and accessible up to the final search date were considered.

The database search identified a total of 183 records, comprising 33 records from Scopus and 150 records from Web of Science.

2.3 Eligibility criteria

Studies were considered eligible when they addressed malaria control or malaria-related community and health-system interventions in Somalia or Uganda and provided information relevant to at least one of the following domains: malaria prevention, diagnosis, treatment, vector control, surveillance, CHW services, community-based service delivery, primary healthcare, health-system strengthening, governance, financing, or One Health-related environmental and contextual factors.

Eligible publications included peer-reviewed original research, observational studies, qualitative and mixed-methods studies, implementation studies, program evaluations, and other empirical studies providing relevant evidence.

2.4 Study selection

The study-selection process is presented in Figure 1, which summarizes identification, duplicate removal, screening, full-text assessment, exclusion, and final inclusion.

2.5 Data extraction

Data were extracted from the 54 included studies using a structured framework aligned with the objectives of the review. The extracted information included publication year, country and geographical setting, study focus, malaria-related interventions, community health worker (CHW) and community-based service components, health-system factors, implementation context, and key findings relevant to malaria control and health-system resilience.

The extracted evidence was organized into six thematic groups: malaria burden, epidemiology and environmental risk; CHW, iCCM and community-based malaria service delivery; health-system strengthening, governance and resilience in fragile settings; community engagement, care-seeking and social context; digital health, surveillance and health-information systems; and cross-cutting workforce and service-delivery evidence. This thematic organization was used to support the narrative synthesis and comparison of evidence from Uganda and Somalia. Where relevant information was not explicitly reported in the included sources, it was not inferred.

2.6 Data synthesis

Because the included studies differed substantially in study design, population, intervention, setting, and reported outcomes, the evidence was synthesized narratively rather than statistically pooled. The synthesis was organized around the major domains identified during data extraction. Evidence from Uganda was synthesized first, with emphasis on community health workers, community-based malaria service delivery, iCCM, supervision, intervention implementation, surveillance, and health-system integration.

Evidence from Somalia was then synthesized according to malaria burden, CHW and community-based service delivery, intervention coverage, health-system constraints, financing, workforce limitations, conflict, displacement, and other contextual barriers.

A comparative synthesis was subsequently undertaken to identify similarities and differences between Uganda and Somalia. Particular attention was given to the feasibility and transferability of lessons from Uganda to Somalia, considering differences in governance, financing, health-system organization, workforce capacity, insecurity, displacement, geography, and humanitarian dependence.

2.7 One Health analytical framework

A One Health-informed framework was used to interpret the evidence across three interconnected dimensions: human health, animal/livelihood systems, and environmental health. The human-health dimension included malaria prevention, diagnosis, treatment, care-seeking, CHW services, surveillance, and access to healthcare. The animal/livelihood dimension considered pastoralism, livestock-associated mobility, settlement patterns, and human–animal–environment interfaces relevant to population movement and healthcare access. The environmental dimension considered climate variability, rainfall, temperature, flooding, drought, water availability, vector ecology, and other environmental factors relevant to malaria transmission.

The One Health framework was used as an analytical lens rather than an eligibility criterion. Therefore, studies were not excluded solely because they did not explicitly use the term “One Health.

2.8 Critical appraisal and risk-of-bias considerations

Consistent with the evidence-mapping purpose of this scoping review, a formal risk-of-bias or methodological quality assessment tool was not applied to determine study eligibility. The objective was to characterize the breadth, nature, and distribution of the available evidence rather than to estimate a pooled intervention effect or exclude studies according to methodological quality.

Nevertheless, methodological limitations reported by the included studies were considered during data extraction, synthesis, and interpretation. Particular caution was applied when comparing evidence from Uganda and Somalia because of differences in study design, population, geographical coverage, outcome measurement, health-system organization, and evidence availability. Evidence from Somalia was interpreted especially cautiously because the available literature was comparatively limited and frequently derived from specific program, facility, humanitarian, or geographically restricted settings.

Accordingly, the comparative synthesis should be interpreted as identifying potentially transferable health-system principles rather than establishing causal effects or equivalence between the two national contexts.

2.9 Reporting and transparency

The review process was documented to ensure transparency in study identification, screening, eligibility assessment, data extraction, and synthesis. The final review includes a PRISMA-ScR flow diagram (Figure 1) and a characteristics table of the 54 included studies (Table 1).

Table 1. Characteristics of the 54 studies included in the scoping review.

The final evidence base consisted of 54 included studies, which were subsequently synthesized according to country, intervention and service-delivery characteristics, health-system factors, community-health workforce components, and One Health-related considerations.

3 Result

The reviewed evidence shows a clear recent increase in research activity. Figure 2 indicates that publications peaked in 2024 and 2025, with 16 studies in each year. Figure 3 shows that Uganda was the most represented setting (n = 12), followed by global studies (n = 10) and Somalia (n = 8). Figure 4 highlights malaria burden as the most common primary theme (n = 4), followed by mHealth and community engagement (n = 3 each), with additional attention to digital health, CHW contributions, iCCM, care-seeking, malaria control, and health-system strengthening.

Figure 5 shows that CHW-related evidence was most prominent (63.0%), highlighting the central role of community health workers in the reviewed literature. iCCM or digital health was represented in 33.3% of studies, while conflict or fragility-related factors appeared in 31.5%, reflecting the importance of both service-delivery innovation and fragile health-system contexts.

3.1 Uganda’s trajectory

Uganda’s transition from early community health initiatives, including the Village Health Team (VHT) approach, toward a more structured national community health system provides an important example of how community-based malaria services can be progressively integrated into the broader health system (30, 33). The Ugandan experience suggests that community health workers (CHWs) are more likely to achieve sustained impact when they are embedded within national and district health structures rather than functioning as temporary extensions of externally funded programs. Evidence from the inSCALE and Bugoye studies further indicates that CHW performance is strengthened when community workers receive appropriate training, regular supervision, facility linkages, and access to essential commodities (9, 31, 34, 35).

A central strength of Uganda’s approach has been the linkage between community-based workers and the formal primary healthcare system. VHTs provide an interface between households and health facilities, supporting early recognition of malaria symptoms, community-level diagnosis and treatment where authorized, health education, and referral of patients requiring higher-level care (9, 10, 31, 32, 35). This linkage also creates an opportunity for health authorities to receive information from communities and strengthen continuity between household-level services and facility-based care. Rather than functioning as an independent parallel workforce, community health workers therefore contribute to the delivery and surveillance functions of the wider primary healthcare system (30, 33, 40).

The importance of health-system support is further illustrated by the experience of community-based malaria service delivery in western Uganda. The implementation of a “pull-system” logistics approach linked community-level workers with facility-based medicine supply chains, facilitating access to essential malaria commodities, including rapid diagnostic tests (RDTs) and artemisinin-based combination therapies (ACTs). The reported 74% correct-care rate for malaria management provides evidence that the quality of CHW-delivered care is influenced not only by individual worker capacity but also by the availability of commodities, supervision, referral mechanisms, and functional health-system linkages (34, 38).

These findings challenge the assumption that expansion of CHW programs can be achieved primarily through recruitment and short-term training. Uganda’s experience instead suggests that community-based malaria control requires a supporting system that includes sustainable financing, standardized supervision, reliable commodity availability, facility linkages, monitoring, and accountability (30, 33–35, 40, 47). Accordingly, the principal lesson for Somalia is not to reproduce the Ugandan VHT model unchanged, but to adapt its system-level principles to Somalia’s institutional, security, humanitarian, and geographic context (13, 19–22).

The One Health relevance of the Ugandan experience lies particularly in the need to connect community-level malaria surveillance with environmental and vector-related information. Malaria transmission is influenced by interactions among human populations, mosquito vectors, climatic conditions, water and environmental systems, and health-system responses (23, 24, 48). A strengthened community platform can therefore provide an operational entry point for linking household-level malaria detection with vector surveillance, climate-sensitive early warning, environmental risk monitoring, and public health response (23, 29, 48). Such integration would allow One Health principles to move beyond a conceptual framework toward practical community-level disease prevention and surveillance.

Overall, Uganda demonstrates that the effectiveness of community health workers depends less on the existence of the cadre itself than on the institutional and operational systems surrounding it. Government ownership, standardized supervision, functional supply chains, facility linkages, and integration into national health planning are therefore the most transferable lessons for Somalia (30, 33–35, 40).

3.2 Somalia: synthesized evidence on the malaria landscape

The evidence from Somalia indicates that malaria control is constrained by the interaction of a substantial malaria burden with conflict, displacement, climate variability, weak health-system infrastructure, workforce shortages, fragmented service delivery, and dependence on external financing (17, 19–22, 29, 48). In contrast to Uganda, where community health workers are more consistently linked to the formal primary healthcare system, the Somali evidence describes a more heterogeneous service-delivery environment in which community-based malaria activities are often implemented through partner-supported programs and may vary across geographic and administrative settings (14, 19–22). Similar challenges have been documented in other fragile and conflict-affected settings, where fragmented financing, workforce constraints, and weak primary healthcare systems can undermine continuity of disease-control services (6, 13, 54).

The reviewed evidence also demonstrates that malaria transmission in Somalia is geographically and environmentally heterogeneous. Climate variability, rainfall patterns, flooding, drought, and environmental change influence vector breeding conditions and population exposure, while insecurity and population displacement can disrupt routine prevention, diagnosis, treatment, and surveillance services (18, 23, 24, 29, 48). These interacting determinants are particularly important in Somalia because large pastoral and mobile populations may experience repeated movement between areas with different levels of malaria transmission and healthcare access (19, 22, 29). Consequently, malaria control strategies that depend exclusively on fixed health facilities may fail to reach populations experiencing displacement, seasonal mobility, or insecurity (14, 19, 21, 29).

3.2.1 Community-based malaria service delivery

Across the reviewed evidence, community-level service delivery emerges as an important mechanism for extending malaria prevention, diagnosis, treatment, and health education beyond fixed facilities. However, the Somali evidence suggests that community-based services are not yet uniformly institutionalized within a single national delivery model (14, 19–22). This contrasts with the Ugandan experience, where Village Health Teams and community-based integrated case-management approaches have been more explicitly connected to primary healthcare facilities and routine health-system structures (9, 10, 30–35).

The Somali evidence therefore points less to the absence of community-based malaria activity than to fragmentation and variable institutionalization. Community health workers and other community-level actors can improve access in underserved populations, but their effectiveness depends on training, supervision, availability of diagnostic and treatment commodities, referral mechanisms, remuneration or incentives, and integration with facility-based services (14, 19–22, 41). Evidence from broader fragile and conflict-affected settings similarly indicates that CHW programs require supportive health-system structures, sustainable financing, and integration rather than functioning as isolated vertical interventions (6, 13, 46, 47).

3.2.2 Malaria burden, access, and health-system vulnerability

The available national evidence indicates that malaria remains an important public-health concern in Somalia despite substantial variation across time and location. The malaria burden is compounded by limitations in surveillance and service access, making it difficult to generate consistently comparable estimates across all regions (17, 19, 21, 48). The reviewed evidence also identifies conflict, insecurity, displacement, inadequate financing, shortages of trained health personnel, and weak infrastructure as persistent barriers to continuity of malaria services (19–22, 29).

These constraints are consistent with evidence from other conflict-affected settings. Musa et al. (2024), for example, highlighted how conflict-related disruption, workforce limitations, financing constraints, and weaknesses in primary healthcare can undermine sustainable disease-control delivery in northeastern Nigeria (54). This comparative evidence strengthens the argument that malaria control in Somalia should be embedded within a resilient, government-led primary healthcare system, rather than implemented predominantly through short-term, vertically organized programs (13, 19, 20, 54).

3.2.3 Community health workers and intervention coverage

The reviewed evidence supports the importance of community-level health workers and community structures for reaching populations that experience barriers to facility-based malaria care in Somalia (14, 19–22, 41). However, a major finding of this review is the scarcity of standardized quantitative evidence on the scale and performance of Somalia’s community-based malaria workforce. Unlike the Ugandan literature, which provides more detailed evidence on Village Health Teams, iCCM implementation, treatment-seeking, quality of care, and health-system linkages (9, 10, 30–35), the reviewed Somali studies did not consistently report nationally comparable indicators of CHW density, malaria-specific population coverage, supervision frequency, diagnostic availability, treatment coverage, or referral completion (14, 19–22).

This evidence gap limits direct quantitative comparison between Somalia and Uganda and should not be interpreted as evidence that community-based delivery is ineffective in Somalia. Rather, it demonstrates weaknesses in the availability and standardization of routine implementation data. Strengthening monitoring should therefore accompany future expansion of community-based malaria services. Priority indicators should include the number and geographic distribution of trained CHWs, population served per CHW, proportion of CHWs receiving regular supervision, availability of rapid diagnostic tests and antimalarial medicines, proportion of suspected malaria cases tested, treatment and referral completion, commodity stock-outs, and population coverage of community-based interventions (14, 21, 42, 49–52).

Available national malaria indicators nevertheless demonstrate continuing epidemiological vulnerability. WHO evidence cited in this review indicates substantial geographic variation in malaria transmission and continuing changes in malaria prevalence and incidence (48). These epidemiological patterns, combined with limited standardized community-workforce indicators, reinforce the need to integrate malaria surveillance, CHW monitoring, commodity information, and population coverage within routine national health-information systems.

3.2.4 One Health relevance to Somalia

The Somali context provides a particularly strong rationale for a One Health-informed malaria-control approach. Human mobility, pastoralism, environmental variability, vector ecology, drought, flooding, and displacement interact to shape malaria risk and access to health services (23, 24, 29, 48). A One Health approach therefore extends malaria control beyond human case management by connecting human health, animal health, and environmental/ecological surveillance (23, 24, 29).

For Somalia, this could involve linking routine malaria surveillance with climate and rainfall information, vector surveillance, population displacement data, and community-level reporting (23, 29, 48–52). Pastoral and mobile communities should also be considered explicitly when designing surveillance and service-delivery systems (19, 22, 29). Such integration would allow malaria programs to identify changing transmission conditions and adapt community-based prevention, diagnosis, treatment, and referral activities accordingly (23, 24, 29).

3.2.5 Implications from the Somalia evidence

Overall, the Somali evidence suggests that the central challenge is not simply a lack of malaria interventions but weak integration, continuity, and institutionalization of community-based services within the broader health system (14, 19–22, 29). The findings support four priorities: strengthening government stewardship of community health services; establishing standardized CHW training, supervision, referral, and reporting mechanisms; ensuring predictable availability of malaria commodities; and integrating malaria surveillance with climate, environmental, mobility, and community-health information systems (19–22, 42, 48–52, 54).

Taken together, these findings provide an important basis for adapting lessons from Uganda. However, Somalia should not replicate the Ugandan model unchanged. Instead, the transferable principles—government stewardship, community-level delivery, facility linkage, routine supervision, reliable commodities, integrated surveillance, and community engagement should be adapted to Somalia’s conflict-affected, climate-vulnerable, mobile, and decentralized context (9–22, 54).

3.3 Comparative policy analysis: Uganda–Somalia governance matrix

Overall, the comparative analysis suggests that Uganda’s principal relevance to Somalia lies in demonstrating the importance of institutional support around community-based service delivery. Somalia should therefore adapt these principles through a nationally coordinated but context-sensitive model capable of operating across stable, remote, mobile, displaced, and conflict-affected populations.

The interplay between environmental drivers, systemic governance challenges, and the proposed One Health interventions is visualized in the conceptual framework presented in Figure 6.

The comparative governance matrix in Table 2 summarizes the principal differences and transferable system principles. The comparison between Uganda and Somalia indicates that the effectiveness and sustainability of community-based malaria control depend not only on the presence of community health workers but also on the institutional systems that support them. The principal difference between the two contexts is therefore one of system organization, institutionalization, and continuity rather than simply the number of community workers available.

Table 2. Comparative governance matrix: Uganda vs Somalia.

Uganda provides evidence of a more structured pathway through which community health workers can be linked to government health structures, health facilities, supervision mechanisms, commodity systems, and routine reporting (33–35). Somalia, by contrast, operates within a more fragmented and partner-supported environment in which the availability and organization of community-based malaria services can vary across geographic and program settings (14, 19–21). This difference has important implications for sustainability.

Evidence from other conflict-affected settings, including northeastern Nigeria, reinforces the importance of rebuilding resilient, government-led primary healthcare rather than maintaining fragmented parallel services (54). The comparison also indicates that not all components of the Ugandan model are equally transferable to Somalia. Government ownership, standardized supervision, facility linkage, routine commodity management, and community-level surveillance represent relatively transferable system principles. However, their implementation in Somalia requires adaptation to insecurity, displacement, limited infrastructure, geographic access constraints, and the continuing role of humanitarian partners. A successful Somali model would therefore require a hybrid approach in which government institutions provide strategic stewardship while humanitarian and development partners contribute technical and financial support within a nationally coordinated framework. The comparative evidence base for Somalia and Uganda is shown in Figure 7, with a greater number of included studies identified for Uganda than for Somalia.

The One Health dimension further distinguishes the proposed adaptation from a simple CHW reform. In Somalia, community-based malaria systems could be connected to environmental and vector surveillance, climate information, population-mobility monitoring, and other relevant health-sector data. This would strengthen early identification of changing transmission conditions while improving coordination between community services and broader disease-prevention systems.

Accordingly, the comparative analysis supports an adaptation rather than direct replication of Uganda’s experience. The priority for Somalia is to institutionalize the functions that make community-based malaria services sustainable while allowing implementation mechanisms to remain flexible enough to operate in conflict-affected and climate-vulnerable settings. The proposed integration of human health, environmental and vector surveillance, animal-health considerations, and health-system response is summarized in the One Health conceptual framework presented in Figure 8.

4 Discussion

4.1 Climate–vector–health-system dynamics

Malaria transmission in the Horn of Africa is influenced by interactions among climatic variability, mosquito vector ecology, population movement, environmental conditions, and the capacity of health systems to detect and respond to changing transmission patterns. In Somalia, recurrent droughts and floods may alter mosquito breeding habitats, population displacement, and patterns of exposure to malaria, creating conditions in which transmission risks can change rapidly (23). Rather than conceptualizing these events simply as climate-induced malaria, they are more appropriately understood as climate-sensitive changes in malaria transmission risk that interact with existing vulnerabilities in communities and health systems.

A One Health-informed malaria strategy could therefore integrate climate and environmental information with human malaria surveillance and vector-related indicators. For example, remotely sensed rainfall, temperature, flooding, and vegetation information could be combined with community-reported malaria cases and vector surveillance to identify areas experiencing increasing transmission risk (24, 29). Such an integrated system could support earlier deployment of interventions, including vector-control measures, community awareness activities, diagnostic commodities, and antimalarial supplies, before or during periods of elevated transmission risk.

The value of this approach is not limited to prediction. Community health workers can serve as an important interface between households, health facilities, vector-control programs, and environmental surveillance systems. Their routine observations may provide locally relevant information on changes in disease patterns, population movement, environmental conditions, and barriers to accessing care. Linking these observations with facility-based surveillance and climate information could strengthen the ability of health authorities to interpret local transmission dynamics.

In this context, the One Health approach should not be interpreted as an additional vertical malaria program. Rather, it provides a framework for coordinating human health surveillance, mosquito-vector information, environmental and climate data, community observations, and health-system response mechanisms. This distinction is particularly important in Somalia, where climatic shocks, displacement, insecurity, and weak infrastructure can interact to amplify barriers to malaria prevention and treatment.

4.2 The digital transformation

The deployment of digital health technologies in Somalia is increasingly viewed as a potential solution for overcoming geographical barriers, improving disease surveillance, and strengthening coordination among malaria-control actors. However, experiences from fragile and conflict-affected settings indicate that digital interventions should not be considered standalone technological solutions. Instead, their effectiveness depends on whether they are embedded within functional health systems with clear governance structures, trained users, reliable infrastructure, and mechanisms for translating data into action (42, 50). These system-level priorities are operationalized in the proposed policy roadmap for strengthening malaria control in Somalia presented in Figure 9.

In Somalia, digital platforms should therefore be designed around the operational realities of rural, remote, displaced, and conflict-affected communities. Where electricity and internet connectivity are unreliable, systems should prioritize offline functionality, low-bandwidth operation, simple interfaces, and interoperability with existing health information systems (42, 50). Such design principles are important because highly complex systems requiring continuous connectivity may exclude the very communities that experience the greatest barriers to healthcare access.

One important opportunity is the development of integrated community-based malaria surveillance platforms. Mobile or offline-enabled reporting by community health workers could facilitate more timely notification of suspected increases in malaria cases, support outbreak investigation, and improve the allocation of diagnostic and treatment commodities (51, 52). Digital stock-monitoring systems could similarly provide information on the availability and distribution of RDTs, ACTs, and other essential commodities across participating facilities and community service points (51, 52).

A national or nationally coordinated malaria dashboard could further support accountability by bringing together selected indicators on malaria cases, commodity availability, community-service coverage, and program performance. In a fragmented health environment, such systems could improve information sharing among government institutions, humanitarian organizations, implementing partners, and donors (42, 50, 51).

Nevertheless, digital transformation should remain an enabling component of health-system strengthening rather than a substitute for it. Investments in digital systems must therefore be accompanied by workforce training, data-quality assurance, governance and privacy safeguards, maintenance capacity, and sustainable financing (42, 50). In Somalia, the strategic use of appropriate digital tools could strengthen surveillance and coordination while supporting a gradual transition from predominantly reactive emergency responses toward more proactive and data-informed malaria control (42, 50, 52).

4.3 Addressing the trust gap

Community trust is a critical but often underestimated determinant of malaria-control success in fragile and conflict-affected settings. In Somalia, healthcare utilization patterns are strongly influenced by accessibility, affordability, security concerns, cultural factors, and previous experiences with formal health services (28). Our analysis of the informal health sector, including community drug shops and private medicine vendors, reveals that patients do not necessarily bypass public health facilities because they prefer informal providers; rather, these providers often represent the most accessible and resilient health infrastructure available in communities affected by conflict and weak health-system coverage (28, 53).

The widespread use of informal providers presents both challenges and opportunities for malaria control. Unregulated medicine distribution may contribute to inappropriate treatment practices, delayed referral of severe cases, inaccurate diagnoses, and potential misuse of antimalarial medicines (28, 53). However, completely excluding these providers from malaria strategies ignores the reality that many communities depend on them as their first point of contact for healthcare. In settings where public facilities are distant, understaffed, or intermittently functional, informal providers frequently fill essential service gaps (28, 53).

A more pragmatic approach may therefore involve regulated engagement with selected informal and private-sector providers rather than assuming that all informal providers can be incorporated into the formal health system. Where feasible, the Ministry of Health and implementing partners could establish minimum standards for malaria diagnosis and treatment, referral of severe cases, reporting, training, and monitoring among participating providers (28, 53). Such engagement would need to remain consistent with national regulations and should be accompanied by appropriate quality-assurance and supervision mechanisms.

Community trust also requires stronger relationships between households and formal health structures. Female Health Workers (FHWs), community leaders, religious leaders, and other trusted local actors may contribute to early care-seeking, health education, acceptance of malaria interventions, and communication about prevention and treatment (46, 53). Their participation could be particularly valuable where gender norms, insecurity, or social barriers limit access to facility-based services (46).

Ultimately, malaria control requires both technical effectiveness and social legitimacy. Strengthening community participation while improving the quality and accessibility of formal health services may help Somalia increase service utilization and create a more inclusive and resilient malaria-control system (28, 46, 53).

4.4 Limitations of the review

This review has several limitations that should be considered when interpreting the findings. First, the available evidence is heterogeneous in terms of study design, population, geographic setting, intervention type, and outcome measurement, which limits direct quantitative comparison between Uganda and Somalia. Second, Somalia-specific evidence on community-based malaria service delivery remains comparatively limited, and some available evidence is derived from program reports or studies conducted in specific geographic or humanitarian settings rather than nationally representative samples (28, 53).

Third, differences in health-system organization, security conditions, financing arrangements, population displacement, and environmental exposure make direct transfer of findings from Uganda to Somalia inappropriate without contextual adaptation. The comparison therefore identifies transferable system principles rather than demonstrating that implementation of the Ugandan model would produce equivalent outcomes in Somalia (28, 42, 53).

Fourth, the review is based on published and indexed evidence and may therefore be affected by publication, indexing, and reporting biases. Programs with limited documentation or unpublished implementation experience may be underrepresented. Finally, because the search period extends into 2026, evidence published or indexed after the specified search cut-off may not have been captured. These limitations reinforce the need for prospective, locally generated evidence on the effectiveness, feasibility, cost, and sustainability of community-based malaria interventions in Somalia.

5 Research gaps and prioritized policy recommendations

Despite continued investment in malaria prevention and treatment, important evidence and implementation gaps remain in Somalia. These include limited nationally representative surveillance data, incomplete integration of community-level reporting with routine health information systems, insufficient evidence on community health worker performance, limited evaluation of female community health workers, and uncertainty regarding the long-term sustainability of donor-supported interventions (43, 47, 50, 53).

Based on the findings of this review, policy actions should be prioritized according to immediacy, feasibility, and system-level impact, rather than presented as a single undifferentiated set of recommendations.

5.1 Immediate priorities: strengthen existing community-based services

The immediate priority should be to improve the reliability and quality of community-based malaria services within existing health-system and partner-supported structures. This includes establishing minimum standards for CHW training and supervision, strengthening referral pathways, improving the availability of RDTs and ACTs, and ensuring that community-level malaria reporting is linked to routine surveillance systems (47, 51, 53).

These actions are relatively feasible because they build on existing community and partner-supported platforms rather than requiring immediate creation of entirely new institutions. Government stewardship should be strengthened while humanitarian and development partners continue to provide technical and financial support within nationally agreed priorities (42, 53).

5.2 Short- to medium-term priorities: workforce institutionalization and coordination

The second priority should be the progressive institutionalization of the community health workforce. Somalia would benefit from developing a nationally coherent framework for CHW recruitment, training, supervision, reporting, incentives, and career progression. A CHW registry and standardized workforce information system could be developed progressively as institutional capacity increases (47, 53).

The role of Female Health Workers (FHWs) should also be assessed and, where supported by evidence and national policy, progressively formalized within the community health workforce. FHWs may improve household-level access and communication in settings where gender norms influence healthcare utilization (46). Their integration should therefore include standardized training, supervision, appropriate incentives, defined responsibilities, and clear linkages with primary healthcare facilities (46, 47).

5.3 Medium-term priorities: integrated surveillance and digital health

The third priority should be to strengthen integrated malaria surveillance. Rather than creating a separate digital platform for every program, Somalia should prioritize interoperability between community reporting, facility-based surveillance, commodity monitoring, and relevant environmental and climate information systems (43, 50, 51).

A progressively developed environmental and malaria surveillance platform could combine selected climate indicators, vector information, malaria case data, population movement information where appropriate, and health-service indicators. Such integration could support earlier identification of changing transmission risks and more targeted deployment of prevention and response resources (42, 43, 50).

A One Health-informed approach would further encourage coordination across human health, animal health, and environmental sectors. In Somalia, this could include linking malaria surveillance with environmental and climate information, vector ecology, pastoral mobility, and other contextual indicators relevant to transmission risk (42, 43, 50).

5.4 Longer-term priority: sustainable financing and government stewardship

Over the longer term, Somalia should strengthen sustainable financing and government stewardship of malaria control. Donor and humanitarian financing will remain important in fragile settings; however, greater alignment of external resources with national priorities is necessary to reduce fragmentation and improve continuity (42, 53).

The objective should not be to eliminate partner involvement, but to progressively move from parallel, project-specific delivery toward a coordinated model in which government institutions provide strategic leadership, while development and humanitarian partners contribute within a nationally aligned framework (42, 53).

5.5 Research priorities

Future research should focus on four priority areas:

• Effectiveness: Evaluation of locally adapted CHW and FHW models for malaria prevention, diagnosis, treatment, referral, and surveillance (46, 47, 53).
• Economic evaluation: Assessment of the cost-effectiveness, affordability, and long-term sustainability of community-based malaria interventions.
• Climate-informed surveillance: Validation of climate- and environment-informed early-warning approaches for malaria transmission and their operational feasibility within Somalia’s surveillance system (42, 43, 50).
• Health-system integration: Evaluation of approaches for integrating humanitarian malaria services with national primary healthcare structures, including community-based reporting, referral systems, commodity management, and routine health information systems (42, 50, 53).

Together, these priorities provide a phased pathway from strengthening existing services to institutionalizing community health structures, integrating surveillance systems, and building sustainable government stewardship. This approach emphasizes feasible system strengthening while allowing Somalia to adapt relevant lessons from Uganda to its own conflict, governance, mobility, environmental, and health-system context.

6 Conclusion

Malaria control in Somalia is fundamentally a health-system and governance challenge rather than solely a clinical problem. Although insecticide-treated nets, rapid diagnostic testing, effective antimalarial treatment, vector-control interventions, and community-based services remain essential, their sustained impact depends on the ability of the health system to deliver these interventions continuously, equitably, and at scale. Fragmented service delivery, limited institutional ownership, inconsistent community health workforce arrangements, climate-related disruptions, insecurity, and dependence on external financing continue to constrain long-term malaria control.

Uganda’s experience demonstrates that community health workers can contribute substantially to malaria control when they are embedded within government-led primary healthcare structures, supported by standardized supervision, reliable commodity supply chains, facility linkages, and sustainable financing. For Somalia, the lesson is not to replicate Uganda’s Village Health Team model directly, but to adapt its core principles to the country’s humanitarian, security, geographic, and sociocultural context.

Based on feasibility and time sensitivity, three policy priorities should be pursued in a phased manner. First, as an immediate and highly feasible priority, Somalia should strengthen coordination and integration of existing community-based malaria services by establishing standardized supervision, reporting, referral, and commodity-monitoring mechanisms across government and implementing partners. Second, as a medium-term priority, the country should formalize and sustainably finance a nationally coordinated community health workforce, including Female Health Workers, with defined roles, training, supervision, incentives, and links to primary healthcare facilities. Third, as a longer-term system-strengthening priority, Somalia should develop an integrated digital and environmental surveillance platform linking community malaria reports with climate, vector, and health-system information to support early warning and proactive resource allocation.

A One Health-informed approach can support these reforms by connecting malaria control with environmental and climate surveillance, community participation, digital health, and multisectoral coordination. However, these innovations should complement rather than substitute for fundamental health-system investments. Digital platforms, climate-informed early warning, and community workforce expansion will have limited impact without reliable financing, institutional governance, trained personnel, essential commodities, and accountability mechanisms.

Ultimately, Somalia’s pathway toward durable malaria control requires a gradual transition from fragmented, project-based interventions toward an integrated and government-led primary healthcare system. Prioritizing immediate coordination and service continuity, followed by workforce institutionalization and longer-term digital and environmental surveillance, provides a feasible pathway for strengthening malaria control while building broader health-system resilience. Such an approach could improve continuity of malaria services and enhance Somalia’s capacity to respond to the interconnected challenges of malaria, climate variability, displacement, insecurity, and future humanitarian crises.

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Footnotes

Edited by: Harapan Harapan, Syiah Kuala University, Indonesia

Reviewed by: Nunzio Zotti, University of Pisa, Italy

Sunday Charles Adeyemo, Institut Superiure de Sante ISS, Niger