Regional hospitals and PPPs in Somali health care

Where Xidig members may contribute

• Hospital management: diaspora hospital managers and administrators supporting management systems and training.
• Biomedical engineering: installing, maintaining and training staff on equipment, so it does not sit idle.
• Clinical training: emergency, intensive care, laboratory and surgical skills, through recognised institutions.
• Contract and PPP skills: public-finance, legal and procurement professionals helping the public side design and oversee contracts.
• Health data: facility assessments and performance monitoring.

Possible services, research, supplier or collaboration roles

• Equipment maintenance services for hospitals, with training for local technicians.
• Management support under contracts with hospitals or implementing agencies.
• Research: a public review of what the NGO contracting model has achieved, and what it costs per person served.
• Training in PPP contract management for public officials.

Who may find this useful

• Doctors, nurses, hospital managers and biomedical engineers, in Somalia and the diaspora.
• Public-finance, procurement and PPP specialists.
• Investors and health companies considering Somali partnerships. This is not investment advice.
• Researchers and students of health policy.

What the evidence shows

What a PPP is. In a PPP, a private company finances, builds or runs a public facility or service under a long contract, and is paid by the government, by users, or both. The public side keeps responsibility for the service, and must manage the contract for its whole life.

Somalia's legal framework.

• The law: PPPs and concessions fall under the Public Procurement, Concessions and Disposal Act, 2015, which defines a concession as "the grant of an interest in a public asset by a Contracting Authority to a non-public entity for a specified period" (World Bank PPP legal snapshot, 2023).
• Who decides: the Act sets up a Concession Technical Unit inside the Ministry of Finance, and gives the Ministry "sole responsibility to issue the Certificate for Concession". Xidig found no public record of the unit's work. The US State Department reported in its 2025 Investment Climate Statement that "A draft PPP law, developed with World Bank assistance, is under review by Parliament."
• Government policy: the federal FY2026 budget framework supports "leveraging the use of Public Private Partnerships (PPPs) framework for commercially viable projects". Its named example is Mogadishu's ports, not health.
• Health rules: WHO (2024) says frameworks for private health providers "remain in draft form and are largely unenforced", and that the requirement for private facilities to be licensed "is not enforced".

The partnership model already in use: contracting NGOs.

• How it works: the Ministry of Health buys services and NGOs deliver them. The EPHS implementation strategy says "only a single NGO (service provider) will be allocated per region".
• In practice: the World Bank-financed Damal Caafimaad project "finances implementation of a package of high-impact health services … using contracted non-governmental organizations". In April 2025 it supported "the day-to-day operations of 227 health facilities with 3,348 health workers" and had reached about 4.5 million people. Its total financing was US$104.25M, and it was due to close on 30 June 2026.
• What comes next: in September 2026, at a Ministry of Health review, the project's coordinator said a follow-on project would be "a long-term one with different phases" (Dawan). No name or amount has been published.
• Why this matters: this is a public-private arrangement that already runs at scale. It pays for services, not buildings.

The regional hospitals today.

• How many: the Essential Package of Health Services (EPHS, 2020) counts "359 PHUs, 680 HCs, 72 DHs, 18 RHs and 18 regional health offices". The 18 regional hospitals (RHs) match the government's proposal.
• Condition, one example: the Galgaduud Regional Hospital in Dhusamareb has 60 beds, and "Seven of the existing buildings have extremely deteriorated and are in dire need of replacement" (Ministry of Health environmental plan, January 2025). Its rebuild is funded by the World Bank, with UNOPS as a sub-implementer.
• Rebuilding already under way:
  • UNOPS said in April 2025 that it is "constructing and rehabilitating six regional hospitals and a central cold chain facility" with the Ministry of Health.
  • WHO and Italy's development agency rebuilt and equipped the outpatient department, operating theatre and radiology unit at Bakool Regional Hospital in Hudur (January 2026).
• Ownership of care: the Ministry's 2022–2026 health plan says "most of the tertiary and secondary level centres are provided by the private sector". A health-sector investment case estimates that "At least 60 percent of health services" are delivered privately.

The claim of only one referral hospital. The government's referral-hospital proposal says the country's only existing referral hospital is in Mogadishu (see More about the source). The Ministry of Health's website described Banadir Hospital in Mogadishu as "a referral hospital for the entire country" (page archived in December 2022). But the word "only" is too strong: UNOPS's list of hospitals being rebuilt includes a "Galmudug Regional Referral Hospital" in Dhusamareb, although it had only 60 beds in January 2025. Specialist care outside Mogadishu is clearly limited.

Lessons from hospital PPPs elsewhere.

• Lesotho: an 18-year PPP, signed in 2008, built a 425-bed national referral hospital and refurbished clinics. The World Bank reports that "The overall death rate at the PPP facilities fell by 41%" compared with the old hospital. It also says the network "has become a considerable financial burden for the Government of Lesotho", and that "PPPs do not eliminate, but rather change and intensify the need for a government's continuous involvement". The World Bank puts the PPP's cost at 34.8% of total government health spending in 2012–15; Oxfam, a critic, reported in 2014 that it took 51% of the government's health budget.
• Kenya: a Senate committee (2020) found that leased hospital equipment went unused because of the "lack of the requisite specialized personnel to run the equipment", and that county governments "were not involved at the conceptualization and designing" of the scheme.
• World Bank evaluation (2016): found "little evidence that fiscal implications are assessed consistently" for health PPPs. It also cites an OECD finding that managing contracts after award "has generally not been an important priority for governments".

The money.

• Federal budget: the FY2026 budget framework proposes about US$42.23M for the Ministry of Health, around 3.1% of planned spending (Ministry of Finance, October 2025; framework paper, not the final budget). Parliament approved a final 2026 budget of about US$1.38 billion on 23 December 2025 (AllAfrica); Xidig has not found its health allocation.
• History: in 2020 health received US$9.4M, 1.9% of the federal budget.
• Households: the Ministry's health plan says "Almost half of all households (48%) finance health expenses using their own income".
• Aid: much health funding comes from donors and runs outside the government budget. A September 2026 preprint reports sharp cuts in external health funding for 2026; it has not been peer-reviewed.

What this means (Xidig's interpretation). A hospital PPP needs a way to pay the private partner for many years: government payments, patient fees, or both. With a small health budget and families already paying out of pocket, that is the hardest part of the government's two hospital proposals (HE-01 and HE-03, described under More about the source). "Private wings" inside public hospitals, which HE-01 lists among its features, would raise money from better-off patients, but would need clear rules so that public care is not squeezed.

Dependencies and implementation constraints

• Staff: doctors, nurses and technicians to use new buildings and equipment.
• A payment model: who pays a private partner, and from what budget.
• Legal capacity: a working concessions unit and published PPP procedures.
• Coordination between the federal Ministry of Health, member-state ministries and donors already rebuilding hospitals.
• Power, water and supplies for hospitals.

Risks and unknowns

• Fiscal risk: long contracts that take a large share of a small health budget.
• Idle equipment without trained staff or maintenance.
• Unequal access: private wings that serve those who can pay while public wards stay under-resourced.
• Duplication with hospital rebuilding already funded by others.
• The population baseline: the government's figure of 16.9 million is below World Bank figures based on UN estimates, of about 19 million in 2024.

Questions members should verify before acting

1. Which 18 hospitals and which eight referral sites are meant, and which are already being rebuilt?
2. What PPP model is intended: build-and-lease, management contract, or full operation?
3. How would a private partner be paid, and from what budget?
4. What will replace Damal Caafimaad, and how will it fund hospitals?
5. What approvals would a hospital PPP need under the 2015 Act?

What is confirmed, and what isn't

Confirmed

• The EPHS count of 18 regional hospitals.
• The 2015 Act and its Concession Technical Unit.
• Damal Caafimaad's scale and closing date.
• UNOPS, WHO and World Bank hospital rebuilding.
• The Lesotho, Kenya and World Bank evaluation findings.

Our interpretation

• Paying a private partner is the main obstacle to hospital PPPs in Somalia.
• NGO contracting is Somalia's most tested public-private model in health.

Not yet verified

• Any hospital PPP under preparation.
• The 2026 status of the six UNOPS hospitals.
• The final approved 2026 health budget.
• Plans for the next national health strategy after 2026.

Relevant next steps

• Follow the Ministry of Health for the successor to Damal Caafimaad and the next health strategy.
• Follow the Ministry of Finance for any PPP procedures or projects.
• Professionals: contact hospitals or implementing agencies about management, maintenance or training roles.