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Antimicrobial Resistance in Somalia: A Growing Public Health Crisis in a Fragile Health System—A Narrative Review of Challenges, Healthcare Gaps, and Policy Recommendations Authors Hassan WM Received 12 May 2026 Accepted for publication 5 July 2026

Published 10 July 2026 Volume 2026:19 624197 DOI https://doi.org/10.2147/IDR.S624197 Checked for plagiarism Yes Review by Single anonymous peer review Peer reviewer comments 4

Editor who approved publication: Dr Hemant Joshi Widad Mohamed Hassan

Department of Internal Medicine, Dr. Sumait Hospital, SIMAD University, Mogadishu, Somalia

Correspondence: Widad Mohamed Hassan, Email [email protected]

Background: Antimicrobial resistance (AMR) has emerged as one of the most serious global public health threats and represents a growing concern in fragile and conflict-affected countries such as Somalia. The increasing emergence of resistant bacterial pathogens threatens the effectiveness of commonly used antimicrobial therapies and contributes to increased morbidity, mortality, healthcare costs, and prolonged hospital stays. In Somalia, prolonged conflict, weak healthcare infrastructure, population displacement, limited diagnostic capacity, and widespread inappropriate antibiotic use have accelerated the development and spread of antimicrobial resistance. Unregulated over-the-counter access to antibiotics, self-medication practices, inadequate infection prevention and control (IPC) measures, and poor antimicrobial stewardship further compound the problem.

Methods: This narrative review synthesizes evidence from peer-reviewed literature, international reports, and programmatic documents to examine the burden of antimicrobial resistance, key healthcare challenges, current response strategies, and policy priorities in Somalia. Literature searches were conducted using PubMed, Google Scholar, Scopus, and grey literature sources including reports from the World Health Organization (WHO), United Nations agencies, and humanitarian organizations. Publications published between 2010 and 2026 were considered.

Results: The findings demonstrate that antimicrobial resistance in Somalia is driven by multiple interconnected factors, including irrational antibiotic prescribing, limited microbiological diagnostic services, weak surveillance systems, healthcare-associated infections, inadequate regulation of pharmaceutical distribution, and persistent humanitarian crises. Current interventions remain fragmented and under-resourced despite increasing global recognition of antimicrobial resistance as a major health security threat.

Conclusion: Strengthening antimicrobial stewardship, improving laboratory and surveillance capacity, expanding infection prevention and control measures, regulating antibiotic sales, and supporting healthcare worker education are critical for reducing the growing burden of resistant infections in Somalia. Sustainable investment in healthcare infrastructure and coordinated national policy implementation will be essential to improving patient safety and protecting the effectiveness of antimicrobial therapies in fragile healthcare settings.

Keywords: antimicrobial resistance, Somalia, antibiotic misuse, antimicrobial stewardship, infection prevention, fragile health systems Introduction

Antimicrobial resistance (AMR) is increasingly recognized as one of the greatest threats to global public health, healthcare delivery, and patient safety. The emergence and spread of resistant microorganisms compromise the effectiveness of antimicrobial therapies, resulting in prolonged illness, treatment failure, increased healthcare expenditures, and higher mortality rates. According to the World Health Organization (WHO), antimicrobial resistance threatens decades of medical progress and could significantly undermine the management of infectious diseases if urgent action is not taken.1,2 Globally, resistant bacterial infections are associated with millions of deaths annually, particularly in low- and middle-income countries where healthcare systems face substantial resource limitations.3 Fragile and conflict-affected settings are especially vulnerable to the spread of antimicrobial resistance because of disrupted healthcare systems, weak regulatory frameworks, limited diagnostic infrastructure, overcrowding, population displacement, and inadequate infection prevention practices.4 The inappropriate use of antibiotics in both human and animal health sectors further accelerates the emergence of resistant organisms and contributes to the global AMR crisis.5 Although AMR represents a global public health threat, its impact is particularly pronounced in low-resource and fragile settings where surveillance capacity, antimicrobial stewardship, and healthcare infrastructure remain limited.

Somalia represents one of the most vulnerable settings for the development and spread of antimicrobial resistance. Decades of armed conflict, political instability, fragile healthcare systems, and recurrent humanitarian crises have severely weakened healthcare delivery across the country. Access to antibiotics without prescription is common in both urban and rural communities, while self-medication practices are widespread because of limited healthcare access, financial barriers, and weak pharmaceutical regulation.6 These factors contribute to inappropriate antibiotic consumption and increased selective pressure on bacterial pathogens.

Limited microbiological diagnostic capacity remains a major challenge within Somalia’s healthcare system. Many healthcare facilities lack adequately equipped laboratories capable of performing bacterial culture and antimicrobial susceptibility testing. As a result, antibiotics are frequently prescribed empirically without microbiological confirmation, increasing inappropriate antibiotic exposure and reducing opportunities for targeted therapy. Recent studies from Somalia have reported increasing resistance among commonly isolated bacterial pathogens, including resistance to ampicillin, ceftriaxone, fluoroquinolones, and other commonly prescribed antibiotics. Emerging multidrug-resistant organisms, including resistant Gram-negative pathogens, have also been reported in healthcare facilities in Mogadishu and other urban centers.7,8

Healthcare-associated infections also represent an important contributor to antimicrobial resistance in Somalia. Overcrowded hospitals, shortages of trained healthcare workers, inconsistent infection prevention and control measures, inadequate water and sanitation infrastructure, and limited availability of personal protective equipment increase the transmission risk of multidrug-resistant organisms within healthcare facilities. Vulnerable populations, including internally displaced persons (IDPs), malnourished children, critically ill patients, and individuals with chronic illnesses, are disproportionately affected by resistant infections and poor treatment outcomes.9

Although awareness regarding antimicrobial resistance has increased globally, Somalia continues to face substantial gaps in surveillance systems, antimicrobial stewardship programs, laboratory infrastructure, and national AMR policy implementation. Reliable epidemiological data regarding antimicrobial resistance patterns remain limited and fragmented, making it difficult to accurately estimate the national burden of resistant infections. These limitations contribute to inadequate monitoring of resistance trends and hinder evidence-based decision-making for antimicrobial use, infection prevention, and public health planning. Strengthening surveillance systems, improving laboratory capacity, and implementing coordinated antimicrobial stewardship programs are essential to address the growing burden of AMR in Somalia and support sustainable healthcare improvements.

Recent international initiatives, including the WHO Global Action Plan on Antimicrobial Resistance, emphasize the importance of surveillance, stewardship, infection prevention, public awareness, and coordinated policy implementation.10 However, implementing these interventions in fragile healthcare settings such as Somalia remains particularly challenging because of financial constraints, insecurity, workforce shortages, and dependence on external donor support. Addressing these challenges requires an integrated and context-specific approach involving surveillance strengthening, policy implementation, healthcare system support, research expansion, and multisectoral collaboration.

This narrative review therefore examines the burden of antimicrobial resistance in Somalia, the major healthcare and public health challenges contributing to resistance, current response strategies, and policy recommendations aimed at strengthening antimicrobial stewardship and improving healthcare outcomes in fragile healthcare settings. The review synthesizes evidence identified through selected literature databases across the defined review period to provide an updated overview of antimicrobial resistance patterns, contributing factors, and response strategies in Somalia.

Methods Study Design

This study employed a narrative review design to synthesize available evidence on antimicrobial resistance (AMR) in Somalia and comparable fragile healthcare settings. The review aimed to provide a comprehensive overview of AMR patterns, contributing factors, healthcare system challenges, and current response strategies relevant to low-resource environments.

Search Strategy

A structured literature search was conducted between January and April 2026 using PubMed, Scopus, and Google Scholar databases. Additional grey literature sources were reviewed, including reports and publications from the World Health Organization (WHO), Centers for Disease Control and Prevention (CDC), World Bank, United Nations agencies, and humanitarian organizations to ensure broader contextual coverage.

Search terms included combinations of “antimicrobial resistance”, “antibiotic resistance”, “antimicrobial stewardship”, “multidrug-resistant infections”, “infection prevention and control”, “healthcare-associated infections”, and “Somalia”. Boolean operators and Medical Subject Headings (MeSH) terms were applied where appropriate to optimize retrieval and improve search sensitivity.

Eligibility Criteria

Publications published in English between 2015 and 2026 were included if they addressed antimicrobial resistance epidemiology, antibiotic utilization, antimicrobial stewardship practices, infection prevention and control measures, surveillance systems, healthcare-associated infections, or healthcare policies relevant to Somalia or comparable low-resource settings.

Studies unrelated to antimicrobial resistance or human health were excluded. Editorials and opinion articles without supporting evidence were also excluded unless issued by recognized international organizations, including WHO or the O’Neill Review on Antimicrobial Resistance.

Study Selection

A total of 68 records were identified through database and grey literature searches. After removal of duplicate records and screening of titles and abstracts, 24 full-text articles were assessed for eligibility. Ultimately, 15 studies and reports met the inclusion criteria and were included in the final narrative synthesis.

Although this review followed a narrative design, a structured and transparent study selection process was implemented to strengthen methodological rigor and minimize potential selection bias.

Data Extraction and Synthesis

Relevant information was extracted using a standardized framework that included study characteristics, drivers of antimicrobial resistance, healthcare system challenges, antimicrobial stewardship interventions, infection prevention and control practices, surveillance limitations, and policy recommendations.

A thematic narrative synthesis approach was applied to organize findings into major domains, including drivers of antimicrobial resistance, healthcare and diagnostic gaps, infection prevention challenges, antimicrobial stewardship practices, and surveillance and policy responses. Owing to heterogeneity across included studies and reports, statistical meta-analysis was not performed.

Quality Appraisal

Formal risk-of-bias assessment tools were not applied because of the narrative design of the review. Nevertheless, priority was given to peer-reviewed studies, international guidelines, and reports from recognized global health organizations demonstrating methodological rigor, credibility, and policy relevance.

Ethical Considerations

Ethical approval was not required because this study utilized publicly available literature and did not involve human participants.

Key Challenges Limiting Antimicrobial Resistance Control in Somalia

Antimicrobial resistance in Somalia is shaped by multiple interconnected healthcare, social, and structural challenges that are characteristic of fragile and conflict-affected settings.4,11 One of the major contributors to antimicrobial resistance is the widespread availability of antibiotics without prescription. In many communities, antibiotics can be purchased directly from pharmacies and informal drug vendors without appropriate medical evaluation, contributing to irrational antimicrobial use and self-medication practices.6,12

Limited microbiological diagnostic capacity remains another critical challenge. Many healthcare facilities in Somalia lack adequately equipped laboratories capable of performing bacterial culture and antimicrobial susceptibility testing.13 Consequently, healthcare providers frequently prescribe antibiotics empirically without laboratory confirmation, increasing inappropriate antibiotic exposure and reducing opportunities for targeted antimicrobial therapy.

Healthcare-associated infections also contribute significantly to the growing burden of resistant infections. Overcrowded hospitals, shortages of trained healthcare workers, inconsistent infection prevention and control practices, and inadequate water, sanitation, and hygiene infrastructure facilitate the transmission of resistant organisms within healthcare facilities.14

Weak antimicrobial stewardship systems further complicate AMR control efforts. Formal stewardship programs remain limited in many healthcare institutions, while standardized prescribing guidelines are inconsistently implemented.10,11

Humanitarian crises, population displacement, poverty, food insecurity, and limited healthcare financing also worsen antimicrobial resistance in Somalia. Internally displaced persons, malnourished children, critically ill patients, and populations living in overcrowded environments often experience increased exposure to infectious diseases while facing barriers to timely healthcare access and appropriate treatment.11,15

A summary of the included literature, major AMR challenges, and key recommendations relevant to Somalia is presented in Table 1.

Current Strategies Used to Improve Antimicrobial Resistance Control in Somalia

Current efforts to address antimicrobial resistance in Somalia focus on improving antimicrobial stewardship, strengthening infection prevention and control measures, expanding diagnostic capacity, and increasing awareness regarding rational antibiotic use. Although these interventions remain limited in scope, growing recognition of antimicrobial resistance as a public health priority has encouraged healthcare institutions and humanitarian organizations to strengthen AMR-related activities.

Several healthcare facilities have increasingly emphasized infection prevention and control measures, including hand hygiene promotion, environmental cleaning, healthcare worker training, waste management, and improved isolation practices for patients with suspected multidrug-resistant infections. These measures are essential for reducing healthcare-associated transmission of resistant organisms.

Efforts to strengthen microbiological diagnostic services have also increased in selected referral hospitals and humanitarian healthcare programs. Expanding laboratory capacity and improving access to bacterial culture and antimicrobial susceptibility testing may enhance evidence-based antibiotic prescribing and reduce unnecessary antimicrobial exposure.

Antimicrobial stewardship initiatives are gradually being introduced through healthcare worker education, prescribing guidelines, and awareness campaigns regarding rational antibiotic use. Public awareness interventions aimed at reducing self-medication and inappropriate antibiotic consumption are also increasingly recognized as important components of AMR control.

International organizations, including the World Health Organization (WHO), humanitarian agencies, and development partners, continue to support health system strengthening activities related to surveillance, laboratory development, and infection prevention in fragile healthcare settings such as Somalia.

Recommendations to Improve Antimicrobial Resistance Control in Somalia

Strengthening Antimicrobial Stewardship Programs

Healthcare facilities should establish structured antimicrobial stewardship programs to promote rational antibiotic prescribing and reduce unnecessary antimicrobial exposure. Standardized prescribing guidelines, prescription monitoring systems, antimicrobial use audits, and continuous healthcare worker education are essential for improving prescribing practices and reducing inappropriate antibiotic consumption. Strengthening stewardship governance and integrating evidence-based prescribing into routine clinical practice may improve treatment outcomes and reduce selective pressure contributing to antimicrobial resistance.

Expanding Diagnostic, Laboratory, and Surveillance Capacity

Improving access to microbiological diagnostic services is critical for strengthening antimicrobial resistance surveillance and guiding targeted antimicrobial therapy. Investment in laboratory infrastructure, bacterial culture services, antimicrobial susceptibility testing, and integrated national surveillance systems should be prioritized. Strengthening laboratory networks and improving data reporting mechanisms may support evidence-based decision-making and facilitate early identification of emerging resistance patterns.

Improving Infection Prevention and Control Measures

Healthcare institutions should strengthen infection prevention and control programs through improved hand hygiene practices, environmental sanitation, healthcare worker training, adequate water and sanitation infrastructure, and access to personal protective equipment. Strengthened infection prevention systems are essential to reduce healthcare-associated infections and limit transmission of resistant organisms.

Regulating Antibiotic Distribution and Sales

National health authorities should strengthen pharmaceutical regulation to reduce over-the-counter antibiotic sales and inappropriate antimicrobial dispensing practices. Regulatory enforcement, pharmacist education, prescription oversight, and strengthened governance mechanisms are necessary to promote responsible antibiotic use and improve antimicrobial control.

Enhancing Public Awareness, Community Education, and Research Priorities

Community education campaigns should increase public awareness regarding the dangers of self-medication, incomplete antibiotic courses, and irrational antimicrobial use. Public engagement initiatives and health education programs should be supported to encourage behavioural change and improve antibiotic use practices. Future research should prioritize identifying local AMR trends and evaluating context-specific interventions.

Strengthening National AMR Surveillance Systems

Developing coordinated national surveillance systems for antimicrobial resistance is essential for monitoring resistance patterns, identifying emerging multidrug-resistant organisms, and guiding evidence-based healthcare policies. Strengthened surveillance should include standardized reporting mechanisms, improved laboratory coordination, and enhanced national data systems.

Supporting Healthcare Workforce Development

Ongoing training for healthcare workers regarding antimicrobial stewardship, infection prevention, rational prescribing, and diagnostic interpretation should be expanded to strengthen healthcare system capacity and improve patient safety. Continuous professional development may improve implementation of AMR control strategies.

Promoting a One Health Approach and Environmental Surveillance

Future AMR strategies in Somalia should incorporate a One Health approach that recognizes the interconnected roles of human health, animal health, and environmental factors in antimicrobial resistance development. Improved regulation of antimicrobial use in livestock, strengthened environmental health measures, and integration of environmental and wastewater surveillance may contribute to reducing AMR transmission. Multisectoral collaboration and long-term healthcare system strengthening will be essential for sustainable AMR control.

A conceptual framework summarizing the major drivers of antimicrobial resistance in Somalia, associated healthcare and diagnostic challenges, and priority response strategies is presented in Figure 1.

Limitations

This narrative review has several limitations. First, Somalia-specific data regarding antimicrobial resistance remain limited, fragmented, and primarily derived from individual healthcare facilities and humanitarian programs. Second, underdeveloped surveillance systems and limited laboratory capacity may contribute to underreporting of resistant infections and inaccurate estimates of antimicrobial resistance burden in Somalia. Third, the humanitarian and security challenges affecting healthcare delivery may limit access to comprehensive epidemiological data from some regions of the country.

Despite these limitations, this review synthesizes currently available evidence to provide insight into the growing threat of antimicrobial resistance and highlights important priorities for strengthening healthcare systems and antimicrobial stewardship efforts in fragile settings.

Conclusion

Antimicrobial resistance represents a growing public health crisis in Somalia and poses a serious threat to healthcare delivery, patient safety, and infectious disease management. Fragile healthcare infrastructure, widespread inappropriate antibiotic use, limited diagnostic services, weak surveillance systems, and inadequate infection prevention measures continue to accelerate the emergence and spread of resistant pathogens.

Although awareness regarding antimicrobial resistance is increasing globally, substantial healthcare and policy gaps persist in Somalia. Strengthening antimicrobial stewardship programs and improving laboratory and surveillance capacity are critical priorities for reducing antimicrobial resistance and improving healthcare outcomes. Additional efforts should focus on expanding infection prevention and control measures, strengthening regulation of antibiotic distribution, and enhancing healthcare worker education to support sustainable AMR containment.

Future national strategies should prioritize coordinated AMR surveillance systems, sustainable healthcare investment, and implementation of evidence-based national action plans. Strengthening healthcare systems and advancing antimicrobial stewardship will be essential to preserve the effectiveness of antimicrobial therapies and improve patient safety in Somalia and other fragile healthcare settings.

Acknowledgments

We are pleased to declare that this research was generously funded by SIMAD University. The author gratefully acknowledges the contributions of healthcare professionals, researchers, humanitarian organizations, and international public health agencies whose published work informed this narrative review entitled: Antimicrobial Resistance in Somalia: A Growing Public Health Crisis in a Fragile Health System—A Narrative Review of Challenges, Healthcare Gaps, and Policy Recommendations.

Author Contributions

All authors made a significant contribution to the work reported, whether in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The author declares no conflicts of interest in this work.

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