Pluralistic care pathways may compound care delays and health inequalities across urban, rural, and pastoralist Somaliland

Health-seeking behavior, healthcare access, and health inequalities in Somaliland are shaped by medical pluralism: people may move among traditional or faith healers, pharmacies and drug sellers, private clinics, and hospitals during the same illness episode. These pluralistic care pathways may differ across urban, rural, and pastoralist communities, yet they are rarely measured as complete therapeutic itineraries. This Perspective develops a conceptual argument, grounded in published literature and policy documents, that the public health concern is not pluralism itself but poorly connected transitions that may accumulate time, cost, and clinical risk before appropriate care is reached. We introduce pluralistic delay as a testable construct and integrate Kleinman's medical sectors, Andersen's Behavioral Model, Levesque's patient-centered access framework, and the Three Delays model into a Somaliland Pluralistic Care Pathway and Delay Framework. The framework hypothesizes fragmented abundance in urban settings, constrained escalation in rural settings, and mobility-amplified delay among pastoralist populations; these patterns are propositions for empirical testing, not estimates of prevalence or causal effects. We propose an equity-oriented “regulate and connect” agenda: risk-based pharmacy regulation, red-flag referral partnerships with trusted community providers, mobile and corridor-based services for pastoralists, referral-linked transport and financing, and routine measurement of pre-facility care pathways. The approach may inform universal health coverage and is consistent with Sustainable Development Goals 3, 10, and 17, the WHO Global Traditional Medicine Strategy 2025–2034, Somaliland's national health and development plans, and African Union Agenda 2063.