Supplying primary care in a fragile state: platform-level financing, idle capacity and the cost of the primary care tier in Somalia’s essential package

In many parts of the world, the health of a nation depends on a simple idea: keeping people healthy is cheaper and more effective than treating them when they are already sick. This is the promise of primary care, a system designed to catch problems early, manage common illnesses, and keep communities well through local clinics and community workers. However, in countries facing conflict or political instability, the money to build and run these systems is often scarce and unreliable. When funds shrink, leaders face a difficult choice: cut costs across the board, or make hard decisions about which parts of the health system to protect. The challenge is that not all parts of the system cost the same to run, and not all parts react the same way when money is taken away. Some parts are like a heavy anchor, with high fixed costs that must be paid regardless of how many patients walk through the door, while others are more like a flexible rope, where costs rise and fall directly with the number of people being served. Understanding these differences is critical for survival, yet it is often overlooked in favor of broad averages that hide the true nature of the problem.

A new analysis of Somalia's health system peels back the layers of these broad averages to reveal a complex and surprising reality. Researchers examined the country's Essential Package of Health Services, a detailed plan that lists every medical intervention the nation aims to provide over the next decade. By breaking down the costs of this plan not just by medical service, but by the specific type of facility delivering it, they discovered that the system is not a single, uniform block of primary care. Instead, it is a collection of four distinct economic engines, each with its own rules for how money is spent. The study found that while the primary care tier—comprising community workers, small local units, and larger health centers—accounts for just over half of the total cost, the way that money is used varies wildly between these different levels. The most striking discovery is that a significant portion of the money spent on primary care is actually paying for empty rooms and idle staff, while the most vulnerable part of the system is the one that relies entirely on paying people to go out and find patients.

The researchers started by looking at the total cost of providing essential health services in Somalia. They calculated that in 2026, the primary care tier would cost approximately 129 million US dollars, or about 7.68 dollars for every person in the country. This is more than double what the system cost per person in 2020, reflecting a growing ambition to reach more people. However, when they looked closer at where this money goes, a clear picture emerged of a system that is nominally focused on primary care but is actually struggling with a mismatch between what it pays for and what it uses. The study separated the costs into two main categories: the "standing costs" of keeping a facility open, such as salaries for staff and the maintenance of buildings, and the "variable costs" of treating patients, such as medicines and supplies. This distinction is the key to understanding why some parts of the system are fragile while others are surprisingly resilient.

The first piece of the puzzle is the community platform, where community health workers travel to villages to provide care. This part of the system is almost entirely made up of wages. There are no buildings to maintain and very few supplies to buy; the cost is simply the people. The study projects that as the program expands to train 2,000 new community health workers every year, the total wage bill for this group will grow by six and a half times. Because there is no fixed infrastructure to spread the cost over, every new patient requires a proportional increase in workers. This means that if funding is cut, the first thing to go is the workforce itself. There is no buffer, no idle capacity to absorb the shock. The money is the people, and if the money stops, the people stop.

In sharp contrast, the primary health units, which are small local clinics, represent a different kind of economic reality. The study found that these units are currently staffed and equipped to a high standard, but they are operating far below their capacity. At the start of the period, nearly 71 percent of the money spent on these units was going toward standing costs—keeping the lights on and paying the staff—regardless of how many patients actually visited. As the number of patients increases over time, this percentage drops dramatically to just 13 percent, because the fixed costs are spread over many more people. This reveals a hidden inefficiency: the country is already paying for a network of clinics that are largely empty. The money is being spent to keep the doors open, but the patients are not walking through them. This is not a problem of building more clinics, but of filling the ones that already exist.

The third component, the health centers, carries the largest single share of the total cost, accounting for nearly 39 percent of the entire package. These facilities show a similar pattern to the primary health units, but less extreme. They also have a high proportion of standing costs that drop as utilization rises, but their wage bills are growing faster, suggesting that capacity is expanding alongside patient numbers. The final piece is the hospital tier, which includes district and regional hospitals. These facilities are dominated by highly specialized staff who are expensive to employ and difficult to replace. Their costs are heavily fixed, meaning that even if patient numbers fluctuate, the bill for salaries and infrastructure remains high. This makes the hospital tier the most protected part of the system during a financial crisis, simply because it is the hardest to cut without causing immediate collapse.

The implications of these findings become clear when the researchers simulated what happens during a severe financial contraction, such as the 61 percent drop in external funding that Somalia has recently faced. In a typical budget cut, money is often reduced evenly across the board. However, because the community platform is almost entirely variable costs, a uniform cut hits it the hardest, effectively eliminating the workforce. The primary health units, with their high standing costs, face a different risk: the money continues to be spent on empty clinics while the potential to serve more people is lost. Meanwhile, the hospital tier, with its high fixed costs, absorbs the least damage because those costs are difficult to reduce quickly. The result is an unmanaged contraction that quietly shifts resources away from primary care and toward hospitals, reversing the country's stated goals without anyone making a deliberate decision to do so.

The study concludes that the cheapest way to expand primary care in Somalia is not to build new facilities, but to utilize the existing ones that are currently sitting idle. The money is already being spent to keep the primary health units open; the missing piece is the demand to fill them. This requires addressing barriers on the demand side, such as the cost of travel for patients or the perception of quality, rather than just pouring more money into construction. Furthermore, the financing of the community health workers needs a deliberate strategy, as they cannot be funded through the same models used for clinics. The research suggests that a smart financing system would pay for the platform itself to keep it open, and then pay for the volume of patients served at a marginal cost, tailored to the specific economics of each level. Without these specific, platform-level adjustments, the goal of a primary-care-oriented health system will remain fragile, vulnerable to the next financial shock, and likely to collapse back into a hospital-centric model by default.