Implementing Somalia's National Transformation Plan 2025–2029 for health-system reform: a policy and practice review of governance, financing, and institutional readiness

Somalia's National Transformation Plan (NTP) 2025–2029 presents an ambitious health-reform agenda centred on maternal and child health, workforce development, health-system strengthening, regulation, financing, digitalisation, and emergency preparedness. The policy challenge is whether the institutional conditions required for implementation can be assembled in a fragile, federal, highly aid-dependent and predominantly mixed-provider health system. This Policy and Practice Review critically examines the implementation readiness of the NTP health chapter and proposes a sequenced framework for converting national commitments into measurable results. A structured narrative review was undertaken from June to July 2026 using peer-reviewed literature, national policy documents, and reports from governmental and international institutions. Evidence was interpreted through the health-policy triangle, the updated Consolidated Framework for Implementation Research (CFIR), applied prospectively to anticipated determinants, and a health-system resilience lens. The synthesis generated six interdependent proposed readiness foundations: a negotiated federal-state governance compact; a technically validated, costed and sequenced operational plan; sustainable financing and strategic purchasing; workforce and regulatory capacity; integrated information, monitoring and public accountability systems; and shock-responsive adaptive management. Important policy strengths include explicit targets for service coverage, workforce expansion, hospital rehabilitation, regulation and digital health. Key risks include inconsistent or under-specified targets and baselines, uncertain fiscal pathways, weak federal-state role specification, and dependence on external resources and non-state providers. Comparative evidence suggests that contracting and pooled financing can expand services when stewardship, fiduciary safeguards, workforce integration, community accountability and learning systems develop concurrently. We propose a phased 2026–2029 pathway prioritising technical validation, essential-service continuity, subnational compacts, workforce payroll transition, interoperable data systems and annual public performance reviews. The proposed framework is prospective and has not yet been empirically validated; consultation with federal and subnational authorities, providers, partners, civil society and communities is required before formal adoption.