Challenges and dilemmas on universal coverage for Non-Communicable diseases in low middle-income countries: evidence and lessons from Somalia.

Background: As Low- and Middle-Income Countries (LMICs) advance toward Sustainable Development Goal (SDG) 3.8, they face a profound epidemiological transition. Somalia serves as a critical case study, grappling with a "double burden" of persistent infectious diseases and a rapidly accelerating prevalence of Non-Communicable Diseases (NCDs), particularly diabetes and hypertension. While the Essential Package of Health Services (EPHS 2020) provides a normative framework for care, a stark gap remains between policy intent and the "effective coverage" required for actual health gains. Methods: This study employs a multi-sectoral secondary data analysis using the Tanahashi Framework to evaluate the implementation of Universal Health Coverage (UHC) for NCDs. We synthesized epidemiological, clinical, and economic data from four primary sources: the Somali Health and Demographic Survey (SHDS 2020), routine health information (HMIS/DHIS2 2022–2025), the Somalia Integrated Household Budget Survey (SIHBS 2022), and Harmonized Health Facility Assessments (HHFA). A "Coverage Cascade" was constructed to identify specific bottlenecks preventing "normative" entitlement from becoming "effective" clinical reality. Results: Data indicates that while 100% of the population is entitled to care under the EPHS, only 3.1% receive regular treatment. A critical "treatment gap" exists, with 61.9% of diagnosed nomadic populations remaining untreated compared to 29.6% in urban areas. Notably, diabetes prevalence among nomadic communities (23.6%) now exceeds that of urban areas (14.6%). While HMIS data shows a 98% increase in hypertension screening between 2022 and 2024, new case enrollment has plateaued, suggesting failures in linkage-to-care. Furthermore, the private sector dominates service delivery (27.4% of total visits), creating financial toxicity for a population where only 2% have insurance. Conclusions: Somalia's current health system, historically structured for acute infectious diseases and trauma, is ill-equipped for chronic NCD management. The country faces a "bicephalous" system: a resource-strained public sector and a dominant, unregulated private sector. To bridge the coverage gap, Somalia must transition from donor-driven projects to domestic-financed models, including hypothecated taxation on Khat and sugary beverages. Without structural "rupture"—including task-shifting to primary health units and mandatory private sector reporting—UHC for NCDs will remain an aspirational mirage.