Humanitarian funding contraction and the risk of cost-related forgone care: a proposed financial-protection transition framework for internally displaced communities in Mogadishu, Somalia

Somalia’s humanitarian health response is contracting within a fragmented, aid-dependent system in which displaced households face direct payments and substantial access costs. National and humanitarian reports document major funding gaps and service reductions, but we identified no published study that directly estimates whether the recent funding contraction has increased household spending, delays in care, treatment interruption or cost-related forgone care among internally displaced communities in Mogadishu. This Current Debate is a purposive policy analysis based on selected peer-reviewed studies, Somali policy documents, humanitarian reports and international guidance; it is not an empirical study or a systematic review. We distinguish financial hardship among households that obtain care from cost-related financial exclusion, a broader construct encompassing delayed, incomplete or completely forgone needed care due to unaffordable direct or access costs. We propose a testable transition framework for both planned service reductions and abrupt withdrawal, linking service-gap assessment and essential-service prioritisation to funded protection from charges, time-limited bridge arrangements, appropriately governed purchasing, medicine and transport support, adaptive social protection and community accountability. A minimum viable monitoring set should combine indicators of service continuity, prescription fill, referral completion and unauthorised charges with household-level distress financing and should report cost-related delayed, incomplete and completely forgone care separately. The proposed pathways and interventions are evidence-informed hypotheses and policy options requiring local co-design, costing, feasibility assessment and prospective evaluation; they should not be interpreted as evidence that humanitarian funding contraction has already caused cost-related forgone care in Mogadishu.