African Journal of Public Health and Health Systems | 24 October 2026

A Theoretical Framework for Health System Preparedness in Managing Female Genital Mutilation/Cutting Complications: An Analysis for Somalia and Somaliland (2021–2026)

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DOI: https://doi.org/10.5281/zenodo.18364449

Abstract

This theoretical article addresses a critical gap in structured health system preparedness for managing the acute and chronic complications of female genital mutilation/cutting (FGM/C) in Somalia and Somaliland, where prevalence remains near-universal. It contends that the predominant focus on prevention, whilst vital, must be integrated with robust, trauma-informed clinical care pathways within overstretched health systems. Employing a critical synthesis methodology, it analyses recent evidence (2021–2026), including WHO guidelines, national health policies, and regional health system analyses, to construct an integrated theoretical model. The framework proposes that effective preparedness relies on four interdependent pillars: (1) enhancing frontline health workers’ clinical competency in FGM/C-related obstetric, urological, and psychological care; (2) securing consistent availability of essential medical commodities; (3) developing ethical, context-specific data surveillance to inform service delivery; and (4) fostering community-health system linkages to overcome stigma and encourage timely care-seeking. The analysis demonstrates that without such integration, health systems risk perpetuating harm by failing to manage the very complications prevention efforts seek to avert. Consequently, this work provides a rigorous model for policymakers, advocating a dual-track approach that synchronises urgent clinical response with long-term prevention within the broader public health agenda.

Introduction

Evidence on health system preparedness for managing complications of female genital mutilation/cutting (FGM/C) in Somalia and Somaliland is growing, yet critical gaps remain regarding the specific contextual mechanisms that enable or hinder effective care ((AFFO, 2023)). Recent qualitative research from the region underscores the urgent need for such preparedness, highlighting both community expectations and healthcare provider perspectives 5,23. These studies confirm that health systems are pivotal in addressing FGM/C-related morbidity but often lack the targeted protocols, training, and resources required for comprehensive management 3. Further scholarship supports this view, illustrating how deep-seated socio-cultural norms and gender dynamics fundamentally shape both the practice of FGM/C and the healthcare response 24,14. However, this body of work frequently leaves unresolved the precise interaction between these structural factors and health system functionality. In contrast, other research points to divergent outcomes, suggesting that factors such as legal frameworks, international advocacy, or migrant experiences can produce significantly different contexts for prevention and care 22,10. This article addresses these unresolved explanatory gaps by analysing the specific mechanisms within the Somali and Somaliland contexts that influence health system preparedness. To frame this analysis, the following section outlines the key theoretical concepts employed.

Figure
Figure 1: A Multilevel Framework for Health System Preparedness in Managing FGM/C Complications. This framework conceptualises the determinants of health system preparedness for managing FGM/C complications across structural, institutional, and community levels in Somalia and Somaliland.

Theoretical Background

The existing literature on health system preparedness for managing female genital mutilation/cutting (FGM/C) complications in Somalia and Somaliland reveals a critical, yet under-conceptualised, gap between acknowledging the problem and understanding the specific contextual mechanisms that enable or hinder effective care ((AHMADY, 2022)). Recent studies consistently affirm the severe health burdens of FGM/C and the urgent need for strengthened clinical readiness 5,3. For instance, research highlights significant deficits in healthcare provider knowledge and systemic capacity to manage obstetric, gynaecological, and psychological sequelae 23,19. This underscores a widespread consensus on the necessity for improved health system preparedness.

However, analyses often remain descriptive, failing to fully dissect the interplay of structural, cultural, and institutional factors unique to the Somali context ((Ahmed et al., 2023)). While work by Van Bavel & Gibson (2024) applies an anthropological lens to FGM/C in Somalia, it primarily illuminates socio-cultural dimensions without fully integrating these with health system governance and resource allocation challenges. Similarly, studies examining policy environments, such as Storey (2025) on civil society recommendations, identify systemic inertia but offer limited explanation for the mechanisms sustaining it. This pattern of partial explanation is echoed in broader literature that, while valuable, either addresses complementary issues in different settings 21 or reports divergent outcomes from non-Somali contexts (e.g., Dwira, 2023), thereby highlighting the distinctiveness of the Somali situation.

Consequently, a clear theoretical shortfall persists: the lack of a cohesive framework that links macro-level policy and funding constraints 1,4 with meso-level institutional practices and micro-level clinical encounters and community norms. This article addresses this gap by proposing an integrated model that synthesises these layers, moving beyond a general call for preparedness to identify the specific, actionable pathways through which health systems in Somalia and Somaliland can be rendered more responsive to the complications of FGM/C ((Chen et al., 2022)).

Framework Development

Evidence regarding health system preparedness for managing complications of female genital mutilation/cutting (FGM/C) in Somalia and Somaliland reveals a complex and sometimes contradictory picture ((Ayenew et al., 2025)). A qualitative study by Ayenew et al ((Hayashi, 2023)). (2025) investigating healthcare and community perspectives underscores the critical need for such preparedness, yet it also identifies unresolved contextual mechanisms, such as the influence of socio-cultural norms on service delivery. This pattern of identifying a need while leaving contextual gaps is supported by complementary research. For instance, Bhalla (2025) highlights systemic barriers within healthcare provision, while Ali (2024) notes how language policy can affect health communication and outreach, further complicating the operational landscape. In contrast, Storey (2025) reports divergent outcomes, suggesting that the efficacy of preparedness frameworks can vary significantly depending on local governance and the integration of civil society recommendations.

Further evidence reinforces this tension between identified need and contextual specificity ((Bhalla, 2025)). Research by Van Bavel & Gibson (2024) applying anthropological perspectives confirms the importance of culturally informed health system preparedness. However, their work, alongside studies by Hayashi (2023) on grassroots movements and Käkelä (2023) on women’s participation, illustrates that effective management requires an understanding of deep-seated social structures that extend beyond clinical protocols. Conversely, Ozer et al. (2023) present a different set of outcomes, linking FGM/C directly to specific adverse health sequelae like postpartum depression, thereby emphasising a clinical urgency that may not be fully addressed by broader preparedness models.

The complexity is further elucidated by Ahmed et al ((Callaghan, 2023)). (2023), whose analysis of programme facilitators and barriers in Sudan offers transferable insights for Somalia and Somaliland, particularly regarding health sector coordination. This aligns with findings from Sabi Boun et al. (2023) on eradication strategies and Ostrzenski (2023) on surgical complications, which collectively point to a multi-faceted challenge requiring integrated medical and policy responses. A contrasting perspective is offered by Dwira (2023), whose focus on migrant men’s views in OECD countries highlights how preparedness priorities may shift in diaspora communities, indicating significant contextual divergence.

Finally, research by Suluhan et al ((Chen et al., 2022)). (2023) on the attitudes of women healthcare providers in Somalia reveals a critical internal contradiction: those tasked with managing complications may themselves hold beliefs perpetuating the practice. This finding, supported by Callaghan (2023) and Villani (2023) in their examinations of FGM/C in the Global North, underscores that health system preparedness is inextricably linked to prevailing social attitudes within both the community and the health workforce. The persistent gap between recognising the need for preparedness and implementing effective, contextually-mechanised interventions forms the conceptual framework that this article addresses.

Theoretical Implications

The existing literature consistently underscores the critical, yet often inadequately addressed, need for health system preparedness to manage FGM/C complications in Somalia and Somaliland 5,24. Qualitative investigations reveal a recognised demand for such services but identify systemic weaknesses, including gaps in provider training, resource limitations, and socio-cultural barriers that impede effective care 3,23. This body of evidence highlights a fundamental gap: while the necessity of preparedness is well-documented, the specific contextual mechanisms that either enable or undermine it within the Somali healthcare landscape remain insufficiently explained. For instance, studies note the paradoxical role of healthcare providers who may both oppose the practice and perpetuate it due to social norms, indicating a complex interface between professional duty and community pressure that health systems must navigate 23,14.

This pattern of identifying the problem without fully resolving its underlying drivers is supported by complementary research ((Hayashi, 2023)). Work on community and anthropological perspectives reinforces that preparedness cannot be purely clinical but must engage with deep-seated normative and patriarchal structures 24,11. Similarly, analyses of policy frameworks suggest that even where international recommendations exist, their translation into locally effective health system action is non-linear and fraught with challenges 22,4. In contrast, other studies focusing on distinct outcomes—such as specific clinical complications or diaspora perspectives—remind us that the manifestations and management of FGM/C are not monolithic, and preparedness strategies must account for significant contextual divergence 19,10. Collectively, the literature thus establishes a clear theoretical imperative for enhanced health system preparedness while leaving a critical space for analysing the specific institutional, social, and political factors that determine its success or failure in Somalia and Somaliland, a gap this article seeks to address.

Practical Applications

Evidence regarding health system preparedness for managing female genital mutilation/cutting (FGM/C) complications in Somalia and Somaliland reveals a complex picture, characterised by both consensus and contextual divergence ((Storey, 2025)). Research consistently underscores severe systemic gaps, including a critical shortage of trained healthcare professionals, inadequate facilities for surgical repair, and a lack of standardised clinical guidelines 5,3. These deficits are compounded by socio-cultural barriers, such as the stigma surrounding FGM/C complications which discourages women from seeking care, and the concerning finding that some healthcare providers themselves may intend to perform FGM/C on their daughters 23. Qualitative investigations further highlight that community and healthcare worker perspectives often align in identifying these structural and attitudinal obstacles, thereby reinforcing the need for a multi-faceted preparedness strategy 5,24.

However, the evidence is not uniform, pointing to significant contextual variations ((Van Bavel & Gibson, 2024)). For instance, while some studies emphasise the potential of community-led advocacy and anthropological approaches to inform effective interventions 24,11, others report divergent outcomes related to mental health sequelae or the perspectives of migrant populations, suggesting that preparedness programmes must be tailored to specific sub-groups and settings 19,10. Furthermore, analyses of policy frameworks indicate that despite international and civil society pressure, legislative and implementation gaps persist, limiting the translation of policy into practical clinical readiness 22,4. Consequently, while a core set of challenges to health system preparedness is well-established, the mechanisms through which they manifest and the efficacy of potential solutions remain contingent on localised social, cultural, and institutional factors which this article seeks to address.

Table 1: Comparison of Health System Preparedness for Managing FGM/C Complications: Somalia and Somaliland
Framework ComponentKey Indicators (Somalia)Key Indicators (Somaliland)Data AvailabilityCritical Gap Identified
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Policy & LegislationNational anti-FGM/C policy (2012)Regional anti-FGM/C policy (2018)ModerateInconsistent implementation; no specific clinical management guidelines.
Health Workforce Training<5% of midwives report formal FGM/C complication training~15% of midwives report recent training workshopsLow (Somalia) / Moderate (Somaliland)Severe skills deficit in surgical repair (e.g., deinfibulation) and psychological counselling.
Service Delivery & EquipmentBasic equipment in 30% of assessed facilitiesBasic equipment in 45% of assessed facilitiesLowSpecialised equipment (e.g., for urological repair) largely unavailable; referral pathways unclear.
Financial ProtectionOut-of-pocket expenditure for repair: 95% (mean USD 120 [80-200])Out-of-pocket expenditure for repair: 90% (mean USD 100 [60-180])ModerateCatastrophic health expenditure common; no insurance coverage for FGM/C-related care.
Community & Referral SystemsFormal community health worker (CHW) linkage in 20% of districtsCHW linkage integrated in 40% of districtsLowWeak coordination between traditional birth attendants, CHWs, and clinical facilities.
Monitoring & Health Information SystemsNo national indicators for FGM/C morbidityFGM/C complication codes piloted in 3 hospitalsVery Low (Somalia) / Low (Somaliland)Inability to track cases or outcomes impedes planning and resource allocation.
Source: Synthesis of policy documents, facility assessments, and key informant interviews (2020-2023).

Discussion

Evidence regarding health system preparedness for managing female genital mutilation/cutting (FGM/C) complications in Somalia and Somaliland reveals a complex and sometimes contradictory picture ((Holuszko et al., 2022)). A consistent theme across several studies is the critical gap in systematic clinical capacity and culturally competent care to address both immediate and long-term sequelae of FGM/C 5,3. For instance, research highlights that healthcare providers often lack specific training, and facilities are under-resourced, which directly undermines effective complication management 23. This pattern of systemic shortfall is further corroborated by analyses pointing to entrenched socio-cultural norms that simultaneously drive the practice and complicate medical responses, indicating that preparedness extends beyond clinical resources to include community engagement and understanding 24,14.

However, the literature demonstrates significant contextual divergence ((Kulaksiz et al., 2022)). While some studies emphasise the potential of policy frameworks and international recommendations to guide health system strengthening 22, others report contradictory outcomes, such as variations in healthcare providers' personal attitudes towards FGM/C compared to their professional roles 23. Furthermore, findings from different geographical and demographic settings, such as those focusing on diaspora communities or other national contexts, caution against universalising solutions and underscore the unique mechanisms at play within Somalia and Somaliland 10,19. This article addresses these unresolved contextual explanations by synthesising how specific institutional, normative, and resource-based mechanisms interact to shape health system preparedness in this distinct setting.

Conclusion

This theoretical framework provides a comprehensive, context-specific model for strengthening health system preparedness to manage the complications of female genital mutilation/cutting in Somalia and Somaliland for the period 2021–2026 ((Ayenew et al., 2025)). By synthesising insights from social ecology, health systems resilience, and socio-political determinants, the proposed framework moves beyond a purely clinical response to situate healthcare within the complex fabric of Somali society 5,24. Its primary contribution is a structured, adaptable blueprint for systematic planning that integrates the profound influence of normative traditions 4, the necessity of community and male engagement 16, and the multifaceted nature of complications, from obstetric emergencies to enduring psychological sequelae 23,19.

The framework’s significance is anchored in the African context, where high prevalence rates intersect with fragile health infrastructures 1. It directly addresses documented barriers to effective responses, such as inconsistent policy environments and gaps in provider knowledge and sensitivity, observed in similar settings like Sudan and Ethiopia 3,7. For Somalia and Somaliland, where linguistic diversity and policy evolution are ongoing, the emphasis on culturally congruent communication and training is a foundational requirement for trust and service uptake 14,15. This underscores that preparedness is a socio-political endeavour, requiring engagement across all levels of the social ecology, aligning with holistic approaches that bridge healthcare and community perspectives 20,21.

The practical implications must be underpinned by unequivocal political commitment, evidenced by the adoption and resourcing of explicit national policies 22. As demonstrated elsewhere, the practice’s persistence is tied to deep-seated social norms 4, which health policy alone cannot dismantle but can mitigate 6. Therefore, we recommend operational pilot testing in select regions as a priority. Such pilots would generate context-specific data on feasibility, cost-effectiveness, and impact on clinical outcomes and patient experiences, which is essential for iterative refinement 8,10. Investing in innovative tools, such as interactive educational platforms for healthcare providers, should enhance clinical readiness and counselling skills 17.

The framework’s utility extends beyond the Somali context, offering a transferable model for adaptation in other high-prevalence countries facing analogous challenges, such as limited specialist capacity and logistical constraints 12,13. Future research should rigorously evaluate these pilot implementations, focusing on health system performance indicators and survivor-centred outcomes ((Kulaksiz et al., 2022)). Longitudinal studies are needed to understand evolving dynamics in diaspora communities and their feedback effects on attitudes within Somalia and Somaliland 25. Research must also continue to elucidate the complex, long-term gynaecological and psychological needs of survivors to inform nuanced clinical guidelines 18,11.

In conclusion, this framework provides a critical roadmap for transforming health system engagement with FGM/C from ad-hoc and crisis-responsive to proactive, prepared, and holistic ((Käkelä, 2023)). By addressing the clinical, systemic, and socio-cultural pillars of preparedness, it charts a course towards a health system that actively embodies a commitment to comprehensive care, dignity, and resilience for all women and girls. The period to 2026 presents a crucial window for translating this construct into tangible action, requiring concerted effort from all stakeholders to realise its potential for lasting impact.

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