Nurse Attrition and Health System Stability in Somalia: A Narrative Health Systems Commentary

Background: Nurse retention is a central determinant of health system resilience, especially in fragile and conflict-affected settings where workforce reserves are limited. Somalia continues to face severe health workforce scarcity, weak regulation, uneven deployment, and financing instability, making nursing attrition a threat to service continuity. Objective: This commentary examines structural and professional determinants of nurse attrition in Somalia and interprets their implications for national health system stability. Methods: A narrative health systems commentary was developed using national and international policy documents, Somalia health workforce reports, World Health Organization workforce guidance, Global Health Observatory indicators, and selected Somali nursing and health workforce studies. Sources were interpreted using a Human Resources for Health systems framework focused on education, labor market absorption, deployment, retention, governance, workforce information, and performance support. Results: Somalia has extremely low nursing and core health workforce density. Differences between 2021 national regulatory landscape figures and 2024 international workforce estimates reflect different reporting sources, definitions, and update cycles rather than a single measured attrition trend. The synthesis indicates that nurse attrition is shaped by salary and employment insecurity, weak regulation, limited career progression, occupational stress, workplace safety concerns, uneven rural deployment, and international migration pressures. Conclusion: Nurse attrition in Somalia should be understood as a health system governance and labor market challenge rather than only an individual career decision. Retention-centered reforms, including salary harmonization, workforce information strengthening, occupational protection, career pathways, and rural retention incentives, are essential for sustainable service delivery and health system recovery.