December 2024

Somalia is classified as the most extremely fragile country in the world (OECD, 2022).  According to OECD (2016), “fragility is the combination of exposure to risk and insufficient coping capacities of the state, system and/or communities to manage, absorb and mitigate those risks.” (OECD, 2016). A multitude of crisis, shocks and uncertainties such as persistent conflicts and violence, political deadlock, recurrent droughts and floods, and fragmented and weak state institutions have turned the country into one of the most challenging operating environments in the world and left it in dysfunctional state of fragility.   State coping capacities reflect the governance and strength of its institutions. Decades of conflict has left the state institutions with a fragmented and weak governance and decision-making structures and shortage of critical resources. The health system has particularly bore the brunt of the state collapse and suffered from fractured governance, low service availability, poor health infrastructure, severe shortage of health workers and limited reliable and quality health data. Today’s Federal Somalia accommodates two levels of health authorities; Ministry of Health at the Federal level (FMoH) and Ministries of Health at each of the Federal Member States (FMS MoH). These MoHs are responsible for leading and coordinating the health sector programmes and activities at national, state, regional and district levels. Multiple external and internal actors such as the UN agencies (WHO, UNICEF, UNFPA, World Bank) and international and local Non-governmental Organization (NGOs) are also involved in the health service planning financing and service delivery in different locations.  Poor governance, coordination, insufficient funding and limited capacity for service delivery have been idenfied as the main drivers of the ineffective planning and responsiveness, overlapping of interventions and poor performance of the health system (MoH Somalia, 2021). Somalia is one of 20 countries in the world with the highest numbers of zero-dose children (UNICEF, 2023). More than 60 percent of children under two years of age have not received any dose of the four basic routine childhood vaccines. Most of these children are in the poorest and most vulnerable segments of the population with low level of formal education and access to routine primary health care services living in remote locations and in nomadic and internally displaced communities. This brief draws evidence from two studies on zero-dose and under-immunized communities in Somalia. The first study assessed the prevalence and determinants of unvaccinated (zero-dose) children in Somalia using the demographic and health data (DHS) (Mohamoud et al, 2023). The second study explored who and where the zero-dose and under-immunized children live, and how orthe strategies used to reach zero-dose children, using the GAVI Vaccine Alliance IRMMA framework (GAVI, n.d). The overarching objective of this policy brief is to shed light on vulnerable and at-risk zero-dose and under-immunized children in the fragile context of Somalia and provide short-term as well as long-term actionable recommendations and policy options for improved and equitable childhood vaccination coverage (Bile et al, 2023). The two studies presented in this brief are part of a larger research project (RAISE) on zero-vaccine dose communities in crisis-affected populations (LSHTM, n.d).